Diagnosis: Back pain; leg pain
Treatment: Laminectomy (63047)
The insurer denied the Laminectomy (63047)
The denial is upheld.

The patient is a female with low back pain and leg pain. Her exam reveals no focal deficit. The patient takes NSAIDs (nonsteroidal anti-inflammatory drugs) for pain, and she has attempted chiropractic care. MRI (magnetic resonance imaging) shows L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) disc protrusion with moderate lateral recess and foraminal stenosis.

The patient was recommended L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) laminectomy.

No, the requested laminectomy is not medically necessary.
The patient's imaging does demonstrate stenosis, but the patient has not attempted an adequate trial of nonsurgical management. The patient has moderate foraminal stenosis that does correspond with the amount of pain, but because it is not documented that the patient has had adequate conservative therapy, the medical necessity of the recommended surgery is not supported. An adequate trial of multimodal therapy would include PT (physical therapy), injections, chiropractic care, amongst others for a minimum of 6 weeks, and up to 3 months, within the last 6 months.

Therefore, given the above, the requested laminectomy is not considered medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As the requested laminectomy is not medically necessary, it is appropriate to deny surgery based upon lack of nonsurgical management.