Diagnosis: Lumbar spinal stenosis
Treatment: Back Surgery (procedure code 0275T)
The insurer denied coverage for back surgery
The denial is upheld

This is a patient with chronic lower back pain and leg pain secondary to lumbosacral radiculopathy, lumbar disc herniation, and lumbar spinal stenosis with neurogenic claudication. The patient reported 8 out of 10 pain level and has tried oral analgesics, analgesic ointments, physical therapy, home exercise program and epidural steroid injections with partial benefit. A magnetic resonance imaging (MRI) was performed that showed broad-based central lumbar (L)1-2 disc extruded disc herniation with cephalad extension to the superior L1 level, with approximate 40-50% thecal sac effacement; Moderate central L3-4 disc bulge with bilateral foraminal disc extension; Moderate L4-5 thecal sac narrowing; Marked central L4-5 disc bulge. Bilateral L4-5 foraminal disc extension which abuts the L4 nerve roots. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

The MILD (minimally invasive lumbar decompression) procedure is generally described as a noninvasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, computed tomography) with contrast media to identify and monitor the compressed area via epidurogram. This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required.

Systematic review found that current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy and the benefits to long term health outcomes are unknown. Minimally invasive surgery had no clinically significant advantage in terms of short- or long-term measures of pain or function. Open discectomies are already performed through relatively small incisions, so it is not surprising to find that outcomes are no better with minimally invasive discectomies. UpToDate notes that less invasive decompression procedures, such as the MILD procedure, appear in observational studies to have lower complication rates than traditional surgical techniques. However, 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 North American Spine Society makes no specific recommendations on percutaneous image-guided lumbar decompression. Centers for Medicare and Medicaid (CMS) has determined that percutaneous image-guided lumbar decompression is not reasonable and necessary and is covered only when provided in an approved clinical study, through coverage with evidence development (CED).

The patient has chronic back and leg pain with spinal stenosis and lumbar disc herniation, who has failed conservative treatment including medication, physical therapy (PT), and epidural steroid injections. The physician is recommending the MILD procedure. The procedure does not have approval from regulatory bodies for routine use. This patient has lumbar disc herniation that would not be addressed by this procedure. The requested procedure is not considered standard of care in the general medical community, as there are significant risks and limitations with this procedure, and it is not found to be more effective than that of a traditional open discectomy.

In summary, the denial of a back Surgery (procedure code 0275T) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.