Minimally Invasive Lumbar Decompression denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for minimally invasive lumbar decompression (MILD) procedure. A review by Kaye and colleagues reviewed several interventions for spinal stenosis including the MILD procedure. The authors concluded that the “superiority in the efficacy of MILD over epidural steroid injections (ESI) was found at the one-year mark in this study.” In addition, the authors found that “the MILD procedure efficacy was statistically significant with improvements in pain, claudication, and disability index scores at the two-year mark.” Deer and colleagues reported that the Lumbar Spinal Stenosis Consensus Group evaluated the peer-reviewed medical literature as a basis for making minimally invasive spinal treatment (MIST) recommendations.

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

A 61-year-old male enrollee has requested authorization and coverage for MILD (minimally invasive lumbar decompression). The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollee’s clinically symptomatic lumbar spinal stenosis. Findings: Three physician reviewers found that the patient has clinically symptomatic lumbar spinal stenosis. The submitted documentation noted that the patient has low back pain. He has not obtained relief with pharmaceutical management, conservative treatments, and physical therapy. The patient has requested authorization and coverage for MILD (minimally invasive lumbar decompression). The Health Plan has denied this request and reported that the requested procedure is investigational for the treatment of this patient.

A 66-year-old female has requested approval for minimally invasive lumbar decompression for treatment of her back pain and bilateral lower extremity pain. Findings: Three physician reviewers found that the patient has a history of bilateral low back, buttock, and leg pain. The pain increases with activity and decreases with rest. She has tried multiple medications, physical therapy, and a TENS unit, without lasting relief. A lumbar spine MRI, three years ago demonstrated moderate to severe central spinal canal stenosis at the L4-5 level with ligamentum flavum hypertrophy. The requested procedure is not likely to be superior over other available treatment options. Chopko and Caraway reported on 78 patients who had undergone the minimally invasive lumbar decompression procedure. Six week follow-up was obtained on 75 patients, and outcomes were generally favorable.

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 Minimally Invasive Lumbar Decompression, then check the rights and deadlines that apply to your plan.