Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Lumbar spinal stenosis and neurogenic claudication.

Treatment: Percutaneous laminectomy (0275T). 

The insurer denied coverage for percutaneous laminectomy (0275T).

The denial is upheld.

This is a male with history of lumbar spinal stenosis and neurogenic claudication. A magnetic reasoning imaging (MRI) of the spine showed moderate to severe central canal stenosis at the lumbar four through five (L4-5) level with moderate left and severe right foraminal stenosis. The patient has failed conservative treatments, such as physical therapy, medication management, and epidural steroid injections. The request is for percutaneous lumbar decompression.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient, given that a percutaneous lumbar decompression is not well established, and it is unclear if this is an endoscopic percutaneous approach.  

The patient is diagnosed with L4-5 stenosis and neurogenic claudication. There are no long-term studies showing clinical safety and superiority to currently utilized minimally invasive and open procedures. The procedure is not well established.

Patients with symptomatic spinal stenosis treated surgically maintain substantially greater clinical improvement than those treated nonsurgical. For patients with lumbar stenosis without spondylolisthesis, a decompression alone is recommended. The Spine Patient Outcomes Research Trial (SPORT) provided level II evidence indicating laminectomy and fusion did provide better results than nonoperative approaches.

The golden rule in performing these procedures has its basis in the concept that underperforming leads to failed back syndrome, whereas over-doing leads to instability. Laminectomy accounts for significant blood loss, surgical site pain, prolonged hospital stay, and weakening paraspinal muscles, thereby leading to possible spinal instability. To minimize this outcome, surgeons rely on newer surgical techniques such as laminoplasty, hemilaminectomy, laminotomy, and undercutting laminotomies. However, no statistically significant differences appear in the literature between laminectomy and laminotomy in terms of clinical outcomes. Preservation of the posterior elements or the "posterior tension band" is the most important factor in preventing instability. However, during minimal invasive approaches such as endoscopic interlaminar approach and bilateral laminotomy, there is an increased risk for neural injury. However, following a learning curve period, data shows the risk of dural tears to be substantially reduced (5 to 15% in laminectomy vs. 2 to 6% in laminotomy).

Another major issue in the minimally invasive spine (MIS) approaches shows in higher rates of reoperation for residual stenosis not adequately addressed in the initial operation. On the other hand, the Spinal Laminectomy versus Instrumented Pedicle Screw (SLIP) study provided level I evidence supporting decompression with fusion since one-third of patients undergoing standalone laminectomy developed instability within four years. The key issue is identifying those subsets of patients who are at risk of postoperative spinal instability in cases of grade I spondylolisthesis.

Up to Date summarizing this area states "Minimally invasive decompression - There is long-standing interest in the development of less invasive decompression procedures, such as percutaneous lumbar decompression and/or minimally invasive lumbar decompression, which appear in observational studies to have lower complication rates than traditional surgical techniques. It is unclear if these newer procedures offer benefit in terms of improved symptoms and function or fewer complications in routine practice compared with standard decompression with laminectomy." The requested procedure is not likely to produce a more clinically beneficial outcome.

The carrier's denial of percutaneous laminectomy (0275T) should be upheld.