Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar decompression surgery.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction
device, without fusion, including image guidance when performed, with open decompression, lumbar; single
level (22867), insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; single level (22869) and
insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or
fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for
primary procedure) (22870). You say that the enrollee is an excellent candidate for this procedure and should
have access based on medical necessity. The Plan denied your request. The Plan says Medical studies haven't
proven that the device is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 insertion of interlaminar/interspinous
process stabilization/distraction device, without fusion, including image guidance when performed, with open
decompression, lumbar; single level (22867), insertion of interlaminar/interspinous process
stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process
stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found interspinous process devices remain experimental, more research is needed
to show safety and efficacy of the devices.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device,
without fusion, including image guidance when performed, with open decompression, lumbar; single level
(22867), insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; single level (22869) and
insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or
fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for
primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to preapprove
lumbar decompression surgery.