Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: lumbar spinal stenosis (LSS)

Treatment: MILD (minimally invasive lumbar decompression) procedure

The insurer denied coverage for MILD (minimally invasive lumbar decompression) procedure

The denial is upheld

This is a patient with a chief complaint of low back pain that travels into their right leg down to the calf. Pain on exam was 0/10, however, pain is 10/10, severe, and sharp shooting pain on a bad day. The patient had 50% (percent) relief with an epidural steroid block. The patient has not participated in physical therapy (PT) in 8 months. The patient has a regular home exercise program. The patient takes Lyrica as needed and over-the-counter medications. The magnetic resonance imaging (MRI) provided demonstrates spondylosis and broad-based disc protrusions at L (lumbar) 3-L4, L4-L5, L5-S (sacral) 1 resulting in mild central canal stenosis, moderate lateral recess narrowing and mild neural foraminal narrowing. There is no mention of ligamentum flavum hypertrophy. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

The MILD (minimally invasive lumbar decompression) procedure is generally described as a noninvasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, computed tomography) with contrast media to identify and monitor the compressed area via epidurogram. This procedure is indicated for central stenosis due to ligamentum flavum hypertrophy only, without the capability of addressing nerve root compression, disc herniation, or facet joint hypertrophy should it be required. Systematic review found that current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy and the benefits to long term health outcomes are unknown. Minimally invasive surgery has no clinically significant advantage in terms of short- or long-term measures of pain or function. Open discectomies are already performed through relatively small incisions, so it is not surprising to find that outcomes are no better with minimally invasive discectomies. 

In summary, the patient has chronic low back and leg pain with mild lumbar spinal stenosis. An outdated MRI reveals mild central canal stenosis with multilevel lumbar disc protrusions, and multiple lateral recess and neural foraminal narrowing. The physician is recommending the MILD procedure. The procedure does not have approval from regulatory bodies for routine use. This patient's multiple disc protrusions and multiple lateral recess and neural foraminal narrowing would not be addressed by this procedure. The requested procedure is not considered standard of care in the general medical community, as there are significant risks and limitations with this procedure, and it is not found to be more effective than that of a traditional open discectomy. The denial should be upheld.

In summary, the denial of percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements (MILD procedure) (code 0275T) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.