Foraminal Stenosis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion. Findings: The physician reviewer found that Evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Wang and colleagues noted that lumbar fusion may be appropriate for patients with degenerative disc disease and disc herniations with radiculopathy when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery consisting of two-level lumbar fusion (CPT codes 20937, 22630, 22632, 22842, 63047 and 63048). The records provided for review document that this patient has failed over five years of conservative, non-surgical treatment for management of her low back and radicular leg pain. Given her symptoms and failure of non-surgical treatment, surgery is an acceptable treatment option. The patient’s foraminal stenosis due to disc height loss supports the requested restoration of disc space height through placement of an interbody device, or with complete resection of the facet joint, which then results in iatrogenic instability and requires instrumentation and fusion. The patient’s primary back pain due to disc degeneration is unlikely to respond to decompression alone.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for requested spinal fusion and decompression surgery. This patient is being treated for vertebrogenic low back pain and a lesion of the lumbar spine. She has continued pain in the lower back with radiation down to her right leg. The patient’s physical examination revealed tenderness in the lumbosacral spine and tingling and numbness in the right leg. The provider has recommended L5-S1 lumbosacral decompression to decompress the thecal sac and address the L5-S1 instability. One study noted that “A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications.

A 60-year-old female enrollee has requested authorization and coverage for endoscopic lumbar discectomy / foraminotomy / dorsal endoscopic rhizotomy at L4-L5 and L5-S1 level under fluoroscopic guidance for treatment of back and leg pain. Findings: Three physician reviewers found that the patient is a 60-year-old female with back and leg pain. Her provider noted a long history of back problems, with a prior fusion for scoliosis from T3-T10, and a later extension T10-L4. The medical records noted that the patient’s back pain had increased over the years, significantly for six months, with left lower extremity pain, as well as neurogenic claudication. Conservative measures were unsuccessful. On examination, motion was limited in the back. Straight leg raising was negative bilaterally. Strength was intact.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for foraminal stenosis was denied, the published record says the denial is worth fighting.