Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spinal stenosis
Treatment: Lumbar stabilization device
The insurer denied the Lumbar stabilization device. 
The denial is overturned

The patient is a female with spinal stenosis. 

Patient with history of lower back pain radiating to left thigh, spinal stenosis and spondylolisthesis. Patient is on meloxicam, Tramadol, Tylenol.

Physical examination was positive for tenderness in the lower back with reduced ROM (range of motion), intact motor strength and sensation. Deferred all treatments per patient request. X-ray lumbar spine and bone density scan was ordered. Patient was counseled on daily exercises and weight loss.

No history of lumbar surgery, not on anti coagulation, BMI (body mass index) less than 40, weighs 180lbs.

Patient has history of lower back pain with radicular pain to both lower extremities up to the calf, 7/10 pain, worsens standing and walking. Has significant stenosis L3-4, L4-5 but L4-5 seems to be worse. Got recent X-rays due to spondylolisthesis at L4-5. Patient is on meloxicam. Patient had epidural blocks that lasted six weeks to two months.

The request is for L4-5 inter laminar spacer.

MRI Lumbar spine 05/09/2019: L2-3: moderate facet arthropathy, mild to moderate broad based posterior disc osteophyte complex with moderate b/l intraforaminal extension. Moderate central spinal stenosis. Mild to moderate foraminal stenosis. L3-4: moderate facet arthropathy, Increase moderate broad based posterior disc osteophyte complex with minimal right para central extension. Moderate intraforaminal disc complex are mildly increased, mildly increased moderate left greater than right neural foraminal stenosis increased. L4-5: Grade 1 spondylolisthesis, severe facet arthropathy. Mild to moderate broad based posterior disc osteophyte complex with moderate right intraforaminal extension. Increased severe central canal stenosis. L5-S1: Mild to moderate facet arthopathy. Mild broad based posterior disc osteophyte complex with b/l intraforaminal extension. Disc contacts b/l S1 nerve roots, mild b/l foraminal stenosis.

Impression: Grade 1 spondylolisthesis L4 on L5. Progressive L4-5 disc space narrowing. L4-5 increased severe right and slight increased moderate left neural foraminal stenosis, mildly increased severe central canal stenosis. Moderate L2-3, increased moderate to severe L3-4, mildly increased severe L4-5 central canal stenosis.

Yes, the health plan should cover the Lumbar stabilization device.

The patient has history of lower back pain with radicular pain to both lower extremities. The patient has tried and failed conservative treatment with medications, exercises and injections. The patient has tried medications such as such as meloxicam and Tramadol and encouraged to continue home exercises. The patient received epidural injections with temporary relief. MRI was significant for severe stenosis at L4-5. Patient is less than 40 BMI, and not on anti coagulation and has had no back surgery. This is a request for L4-5 inter laminar spacer.

As per the medical literature, interspinous lumbar disc spacer is a minimally invasive procedure for patients with lumbar spinal stenosis who have failed conservative treatment. Compared with extending conservative treatment or traditional spinal surgery, interspinous lumbar decompression relieves symptoms of intermittent neurogenic claudication secondary to moderate LSS (lumbar spinal stenosis) in the majority of patients through two years. In one of the journal  articles, study showed that the Interlaminar stabilization provides benefits beyond decompression alone and may extend the durability of the decompression procedure.