Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 53-year-old male with a history of spinal stenosis of the lumbar region with 
neurogenic claudication and lumbar disc herniation. On 10/19/22, the provider recommended 
L3-4 and L4-5 posterior decompression and L4-5 microdiscectomy. X-rays of the lumbar spine on 
11/16/22 showed moderate-to-severe degenerative disc disease, most pronounced at L5-S1 with 
endplate on endplate apposition and osteophytes. In addition, both hips had severe degenerative 
arthrosis with superolateral bone-on-bone apposition in the setting of CAM configurations of the 
femoral heads. The Health Insurer has denied the requested surgery as not medically necessary.  
The physician reviewer found that the records indicate that this patient is being treated for spinal 
stenosis of the lumbar region with neurogenic claudication and lumbar disc herniation. The 
patient presented with lower back pain and his symptoms include radicular left lower extremity 
pain. On review of the documentation regarding the patients previous therapeutic modalities 
attempted  there  is  a  lack  of  detail  demonstrating  trial  and  failure  of  recent,  reasonable, 
comprehensive less invasive conservative care measures. The provider noted that the patient 
underwent 10 sessions of chiropractic treatment over a period of greater than five months. 
However, there is a lack of an indication of any formal physical therapy. Additionally, the patient 
indicated that he has tried epidural steroid injections, yet previous treatment with injection 
therapy is not reported in the available medical documentation. The treatment plan on the 
10/19/22 examination noted epidural steroid injections versus the requested surgical procedure. 
All forms of conservative treatment should be completed prior to consideration for surgical 
intervention. This is corroborated by Zaina and colleagues who noted that, No clear benefits 
were observed with surgery versus non-surgical treatment. Similarly, Bydon and colleagues 
commented that, A trial of conservative therapy may be considered for patients with low-grade 
spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may 
include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical 
options may include decompression alone or decompression and fusion. Bagley and colleagues 
reported that, The diagnosis of lumbar stenosis can be difficult, and involves a combination of 
radiological and clinical findings. Treatment ranges from conservative measures with physical 
therapy and core strengthening, to steroid injections in the facet joints or epidural space, to a 
more radical solution with surgical decompression. Although the records reference that the 
patients symptoms include left leg radicular findings, the patients objective examination did not 
demonstrate any neurological deficits. Overall, there are limited large-scale, long-term clinical 
studies  showing  the  safety  and  efficacy  of  the  requested  laminectomy,  facetectomy  and 
foraminotomy in this patients clinical setting. For these reasons, the requested laminectomy, 
facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each 
additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for 
primary procedure) is not medically necessary for treatment of this patient.