Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested reimbursement for low back disc surgery (lumbar endoscopic discectomy) for treatment of the enrollees low back pain and bilateral leg pain. Findings:  Three physician reviewers found that the patient is a 62-year-old male with back pain.  An MRI of the lumbar spine showed mild facet hypertrophy at L1-2, osteophyte and mild canal narrowing at L2-3, and at L3-4 and L4-5, mild canal and left foraminal stenosis with possible root impingement.  At L5-S1, there was bulging and mild right foraminal stenosis. The providers impression was advanced degenerative disc disease at L1-2 and L2-3, small posterior annular fissure at L3-4, mild canal stenosis from L2-3 through L4-5, and possible nerve root impingement of the right L5 and left L3 and L4 roots.  A few months later, another MRI of the lumbar spine described a mild osteophyte complex at L1-2 with mild thecal sac impression, minimal foraminal narrowing without impingement on the nerve roots, and no spinal stenosis.  At L2-3, there was a moderate osteophyte complex with moderate to severe thecal sac and nerve root compression, mild foraminal narrowing without impingement, and no stenosis.  At L3-4, there was mild to moderate osteophyte impression, foraminal narrowing and root compression, and root impingement, more severe on the left.  Similar findings were described at L4-5, with minimal canal stenosis.  Disc narrowing was moderate at L2-3, and mild at the other levels. The providers impression was multilevel degenerative changes.  The medical records noted a history of low back pain for 7 years, worse for 1.5 years, with radiation to both legs, and numbness and tingling on the right.  No conservative treatment was noted.  On examination, there was no sensory loss, the left patellar reflex was absent, strength was intact, and motion was painful and limited.  The patient underwent destruction by thermal ablation of the paravertebral facet joint nerves, lumbar laminotomy and foraminotomy with decompression of the nerve roots, right L3-4.  The patients diagnoses included lumbago, lumbar arthritis without myelopathy, lumbar bulging/herniated disc, lumbar degenerative disc disease, lumbar foraminal and spinal stenosis, and lumbar radiculitis.  No untoward events were noted.  The Health Plan has denied reimbursement for low back disc surgery (lumbar endoscopic discectomy).  Per the Health Plan, the procedure at issue was investigational for the treatment of this patient.  In most patients with low back pain, symptoms resolve without surgical intervention, and with the use of non-surgical treatment, including physical therapy and nonsteroidal anti-inflammatory medications (NSAIDs).  Surgery for non-radicular back pain associated with degenerative changes is no more effective than intensive rehabilitation.  There is limited evidence supporting the value of facet joint interventions, and there is need for further study to obtain more conclusive information.  In this patients case, there is no documentation of conservative management, or the response to it, prior to the surgical procedure.  All told, the superior efficacy of the low back disc surgery (lumbar endoscopic discectomy) performed has not been established.