Diagnosis: back pain
Treatment: Percutaneous Laminotomy/Laminectomy (Spine Surgery)
The insurer denied Percutaneous Laminotomy/Laminectomy (Spine Surgery). The health plan's determination is overturned.

This is a female who has spinal stenosis with neurogenic claudication. She has low back pain with diffused bilateral low extremity pain. Her pain level is 7.5/10. She has increased pain with walking and standing. She has tried home exercise, chiropractic manipulation, pain medications, and epidural injections without adequate pain relief. Magnetic resonance imaging (MRI) showed moderate to severe stenosis at L (lumbar) 3/4 and L4/5 with ligament flavum hypertrophy and grade 1 L4-5 spondylolisthesis.

Percutaneous Laminotomy/Laminectomy (Spine Surgery) is medically necessary for this patient.
This patient has severe pain from spinal stenosis. She had failed extensive conservative treatments. Her pain is severe. Further treatments are medically necessary to improve her pain and function. There are multiple well-designed clinical trials that showed long-term improvement in pain and function for patients with spinal stenosis from ligament flavum hypertrophy. The alternative surgical option is lumbar decompression and fusion, which is a major spine surgery, associated with significant risks and complications.
This patient has spinal stenosis with neurogenic claudication. Her magnetic resonance imaging (MRI) showed ligament flavum hypertrophy with resultant moderate to severe stenosis at L3/4 and L4/5. Current clinical trials supported the effectiveness of the requested procedure for this patient.