Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided decompression (PILD) surgery.

You asked the Plan to pre-approve the PILD surgery. You say that it is felt that this PILD procedure is medically necessary and is covered through the CED study. The Plan denied your request. The Plan says the criteria for this procedure are not met in this case.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that PILD procedures may be covered through CED when provided within an approved trial of prospective, longitudinal study. The trial through which coverage is requested in this case is NCT03072927 which has inclusion criteria including that the enrollee be diagnosed with LSS with neurogenic claudication. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PILD surgery. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates evidence of lumbar spinal stenosis on an MRI but the patient's review of systems and history and physical are not consistent with a clear diagnosis of neurogenic claudication. The record includes a generic letter that is unsigned which indicates neurogenic claudication is present, but it is not consistent with the actual review of systems and the history/physical. The actual medical diagnoses do not list neurogenic claudication as a diagnosis but rather include lumbar post laminectomy syndrome, lumbar radiculopathy, lumbar spondylosis, and low back pain. The patient's pain is primarily in the low back and radiates to the legs only sometimes.

The documentation does not clearly describe claudication with specifics in the patient's history and physical and review of systems. The patient denies acute weakness, numbness, tingling, bowel/bladder dysfunction, bone pain, joint pain, muscle cramps, aches, stiffness. She denies numbness of arms/legs, poor balance, unsteady gait, tingling, or altered sensation. There is no detailed patient or objective physician description of claudication in the legs after a period of walking, in relation to inclines or specific movement on the actual history and physical. The back pain appears predominant, and the leg pain may be due to the patient's history of history of lumbar radiculopathy or there may be a condition of peripheral vascular disease, causing vascular claudication. There is no detailed documentation from the patient or physician in the actual history and physical of symptom triggers and alleviators, timing of onset and time of relief, detailed location of symptoms if they do occur in the legs and nature of the symptoms and association with posture. The generic form letter included in the documentation stating the patient has symptoms with ambulating over 200 feet is not supported by the physician and patient's subjective and objective portion of the document.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PILD surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-guided decompression (PILD) surgery.