Laminectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a re-do of L4-5 laminectomy posterolateral fusion with bone morphogenic protein (BMP) and compression-resistant matrix (MasterGraft) as well as pedicle screw instrumentation. The records document that this patient underwent laminectomy surgery. The patient was known to have mild spondylolisthesis prior to surgery, which the provider indicated required a limited decompression laminectomy. The provider noted that the patient’s back pain and radiculopathy progressed after a short period. Evaluation with imaging revealed progression of the spondylolisthesis at 11 mm versus 4 mm prior to surgery. The patient’s provider has recommended a revision decompression and instrumentation with posterolateral fusion.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for minimally invasive lumbar decompression (MILD) surgery. One study evaluated patients that had lumbar epidural steroid injections (ESI) and MILD surgery for symptomatic lumbar spinal stenosis. This study demonstrated that MILD surgery provided statistically significantly better pain reduction and improved functional mobility versus treatment with ESI. Another trial compared MILD combined with conventional medical management versus conventional medical management alone for lumbar spinal stenosis with neurogenic claudication. At two years, patients who had MILD and conventional medical management demonstrated significant improvements in walking time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laminectomy to be performed within the next two weeks.Researchers conducted a systematic review of the recent literature, and their review found that the literature demonstrates that decompressive surgery is more effective than land-based exercise in the management of lumbar spinal stenosis. However, given the condition's slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land-based exercise be considered prior to consideration of surgical intervention. Researchers recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery at L5-S1. Researchers evaluated the functional outcomes of laminectomy and laminotomy for the surgical management of patients with lumbar spine stenosis. The authors concluded that there were no statistically significant differences demonstrated between laminectomy and laminotomy outcomes, for lower back pain, leg pain, or disability. Researchers found that, “No clear benefits were observed with surgery versus non-surgical treatment.” The authors stated that, “High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.” Medical literature reported that among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically me…

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Laminectomy, then check the rights and deadlines that apply to your plan.