Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbosacral Radiculopathy at lumbar spine level 4-5 (L (lumbar) 4-5). 
Treatment: Back surgery (procedure code 62380). 

The insurer denied coverage for back surgery (procedure code 62380). 

The denial is upheld. 

The patient is a female with a past medical history of disc displacement, lumbosacral radiculopathy at lumbar spine level 4-5 (L4-5), foraminal stenosis, low back pain, and other intervertebral disc displacement, lumbar region. The provider noted that the patient had low back pain for many years and had tried physical therapy, chiropractic care, injections, nonsteroidal anti-inflammatory drugs (NSAIDs), and the pain had persisted. The epidural steroid injection provided only temporary pain. On examination the patient had increased pain with flexion and extension, worse on flexion. There was increased pain with facet loading at L4-5, L5-sacral level 1 (S (sacral)1) on the right. There was increased pain on lateral rotation with decreased range of motion (ROM) due to pain and stiffness. The strength was 5/5. There was decreased sensation of the right lower extremity over the medial leg and lateral leg. The straight leg test was positive bilaterally. The gait was antalgic. The provider performed a right L4-5 lumbar endoscopic foraminoplasty and discectomy. 

According to Chen et al, "Over the 1-year follow-up period, percutaneous transforaminal endoscopic discectomy (PTED) did not show superior clinical outcomes and did not seem to be a safer procedure for patients with lumbar disc herniation compared with microendoscopic discectomy (MED). PTED had inferior results for median disc herniation, whereas MED did not seem to be the best treatment option for far-lateral disc herniation." 

Per Gadjradj et al, "There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between percutaneous transforaminal endoscopic discectomy (PTED) and open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). High-quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking." 

There is no evidence that endoscopic discectomy improves health outcomes. 

The procedure code does not need final approval from the appropriate regulatory bodies for this diagnosis. 

The patient met the criteria, she had intractable right sciatica that had not responded to multimodal conservative treatment and had imaging confirmation of right L5 nerve root compromise. 

Compared to open discectomy there is no evidence that endoscopic discectomy produces better outcomes for a central and paramedian disc herniation as in this patient. 

There is no evidence that endoscopic lumbar disc removal is more beneficial based on the peer-reviewed literature. As summarized in Up to Date "Minimally invasive procedures - Minimally invasive surgical approaches that utilize techniques to further reduce incision size and the area of dissection have been introduced as potential alternatives to standard open discectomy and microdiscectomy. Until more definitive evidence is available showing clear advantages for alternative surgical techniques, our preference is for standard microdiscectomy or open discectomy for patients with lumbar disc herniation and radiculopathy who are appropriate surgical candidates." 

There is no increased risk from using an endoscopic technique compared to an open procedure. 

The carrier's denial of back surgery (procedure code 62380) should be upheld.