Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar Radiculopathy

Treatment: initial primary lumbar microdiscectomy (laminotomy, laminectomy, or hemilaminectomy),

The insurer denied coverage for initial primary lumbar microdiscectomy (laminotomy, laminectomy, or hemilaminectomy),

The denial is overturned

The patient is a male with a history of lumbar radiculopathy. He had a neurosurgical televisit. He has a history of left leg and foot numbness and weakness as well as stinging pain in the left-sided low back and left leg.  The leg pain is worse than the back pain. He states the symptoms have been present and worsening. The patient states the pain got bad two weeks before his daughter was born. He also has numbness and tingling in the lateral two toes of the left foot in the L (lumbar)5-S (sacral)1 distribution. He has undergone two epidural steroid injections. This gave the patient three weeks of 75% (percent) improvement. He had a repeat injection which gave him one week of 25% improvement but no lasting relief. He has previously undergone physical therapy. The patient is taking gabapentin and still has left-sided low back and buttock pain that is incapacitating. He takes Tylenol as needed as well.

He has been experiencing episodic pain since injuring his backwhile moving. He has had annual episodes of pain, which would self-resolve until his most recent episode that began without event. The pain is more severe and constant than previous episodes. The patient did undergo two epidurals as noted above. He decided to hold off on a third injection since the previous one was not significantly helpful. He states gabapentin has brought his pain down from 10/10 to 4/10. 

As noted above, the patient has been participating in physical therapy for months without any significant relief in his symptoms. The patient did undergo an EMG (electromyography), the report of which is located in another doctor's note that states he has left subacute mild S1 root dysfunction. The physical exam states: The patient localizes pain in the left gluteus and down the left leg in the L5-S1 distribution. Motor strength to testing against manual resistance in a seated position is 5/5 of extensor hallucis longus, tibialis anterior, gastrocnemius, quadriceps, hamstrings, hip flexors, abductors, and adductors bilaterally. He has numbness in the left L5 and S1 distributions of the calf, foot, and ankle. He has some decreased sensation to light touch in the left L4 distribution of the thigh but not in the calf and ankle. 

The initial primary surgery is medically necessary. Given all clinical records as well as the appeal letter, the member's appeal letter with clinically significant information, the office notes prior to surgery, it is clear that the patient had failed conservative treatment. He had significant pain and exam findings of a positive straight leg raise on the left, atrophy left calf, unable to toe walk on the left, decreased sensation, EMG positive for left S1 radiculopathy consistent with his large disc herniation at L5-S1 on the left with nerve root compression at S1. Intraoperatively the disc fragments were causing L5 and S1 nerve root compression. The surgery meets clinical guidelines and standard of care.

Treatment is varied depending on the etiology and severity of symptoms. However, conservative management of symptoms is generally considered the first line. Medications are used to manage pain symptoms including NSAIDs (Non-Steroidial Anti-Inflammatory Drugs), acetaminophen, and in severe cases, opiates. Radicular symptoms are often treated with neuroleptic agents. Systemic steroids are often prescribed for acute low back pain, although there is limited evidence to support its use.
Nonpharmacologic interventions are often utilized as well. Physical therapy, acupuncture, chiropractic manipulation, and traction are all commonly used in the treatment of lumbosacral radiculopathy. Of note, the data supporting the use of these treatment modalities is equivocal. Interventional techniques are also commonly used and include epidural steroid injections and percutaneous disc decompression. In refractory cases, surgical decompression and spinal fusion can be performed (2).

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an initial primary lumbar microdiscectomy (laminotomy, laminectomy, or hemilaminectomy is overturned. Medical Necessity is substantiated.