Blue Cross of Idaho
Lumbar Spinal Surgery Pre-authorization Guidelines
Subject Lumbar Laminectomy, Hemi-Laminectomy, Diskectomy
Last Reviewed 02/2015
Back pain, with and without radicular symptoms, is one of the most common complaints for which patients seek medical care. This results in significant direct and indirect health care costs. The manner in which back pain is treated can have a significant and long lasting impact on patient well-being.
There is significant geographic variability in the treatment of back pain and radiculopathy. According to the Dartmouth Atlas of Healthcare, patients in Idaho are four times more likely to undergo back surgery than patients in regions with the lowest rates, with no difference in outcomes.
1. Prior-authorization is required for elective procedures and physicians should submit requests to Blue Cross of Idaho`s Medical Management Department at least two weeks prior to the anticipated date of an elective surgery.
2. The minimal documents necessary to accurately and expeditiously complete pre-authorization requests for lumbar decompression are:
a. Specific procedures requested with CPT/ICD-9 codes and disc levels indicated
b. Office notes, including a current history and physical exam
c. Detailed documentation of extent and response to conservative therapy, including outcomes of any procedural interventions, medication use and physical therapy notes
d. Most recent radiology reports for MRI`s, CT`s, etc. Imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede.
e. Medical clearance reports (as indicated)
3. The patient must have an appropriate indication for lumbar decompression as defined in the Indications for Lumbar Laminectomy, Hemi-Laminectomy, Discectomy section below
4. The patient must have significant symptoms that correlate with physical exam findings AND radiologist-interpreted imaging reports including:
a. Significant functional impairment or loss of function resulting in inability or significantly decreased ability to perform normal, daily activities of work, school, or at-home duties.
b. Persistent, debilitating pain is defined as: Significant level of pain on a daily basis defined on a Visual Analog Scale (VAS) as greater than 4. Pain on a daily basis that has a documented negative impact on activities of daily living despite optimal conservative therapy as described below.
The following guidelines may not apply to patients with traumatic spinal fractures or dislocations, primary infections, neoplasms of the spine or those with “red-flag” symptoms such as severe or rapidly progressive symptoms of motor loss, neurogenic claudication or cauda equina syndrome.
5. The requesting surgeon should have personally evaluated the patient on at least two occasions prior to requesting surgery.
6. Patient has participated in optimal conservative care as specified in the Indications for Lumbar Laminectomy, Hemi-Laminectomy, Discectomy section below.Lumbar laminectomy, hemi-laminectomy, discectomy surgery is considered not medically necessarywhen the patient demonstrates substantial improvement on clinical re-evaluation as a result of these measures. Conservative care includes the following:
a. The use of prescription oral analgesic medications, preferably anti-inflammatories AND
b. Documented participation in a formal, active physical therapy program or through a Blue Cross of Idaho Spine Center of Excellence. AND
c. Evaluation and appropriate management of associated behavioral, cognitive, and addiction issues, if present
d. Other conservative measures which may not be substituted for those above but which may be used adjunctively can include:
§ A home exercise program
§ Activity modification, as appropriate
§ Facet or epidural injections
§ Other measures
e. The purpose of performing conservative measures is not to simply fulfill surgical pre-requisites or add complexity to the pre-authorization process. According to best-practice guidelines and evidence-based medicine, initial and preferred long-term treatments for back pain are conservative in nature. It is recognized that some individuals with back pain will require surgery. Many patients will obtain lasting benefit from conservative treatments and thus avoid more invasive procedures. One of the primary goals of this policy is to help identify and most appropriately manage these patients.
7. All members should be screened for medical co-morbidities and undergo thorough medical clearance as indicated.
The following indications for lumbar laminectomy, hemi-laminectomy, discectomy may be considered Medically Necessary when all other reasonable causes of pain have been ruled-out and all other requirements have been met (as described in the General Requirements portion of this document):
1. Acute Neurologic Deterioration
a. Surgery may be considered medically necessary without undergoing conservative management for individuals with “red-flag” symptoms such as:
§ Symptoms due to Cauda Equina Syndrome (saddle anesthesia, acute bowel or bladder dysfunction) confirmed by imaging
§ Rapidly progressive neurological impairment (foot drop, extremity weakness or decreased sensation) as documented on serial physical exams.
2. Herniated Disc:
a. This applies to
§ Initial disc herniation OR
§ Recurrent same-level disk herniation following prior discectomy when:
o Neural structure compression is again demonstrated by appropriate imaging.
o Patient experienced significant initial relief of symptoms following prior discectomy.
o There must be at least a 6 months’ time span since previous disk surgery.
o For the current episode, the patient must have recurrent neurogenic symptoms and impairment or loss of function that has not responded to a minimum of 12 weeks of coordinated conservative care (as described above in #6 under General Requirements for Lumbar Laminectomy, Hemi-Laminectomy, Discectomy).
b. Surgery may be medically necessary when all of the following criteria are met:
§ Member has failed at least 12 weeks of conservative therapy which must include
§ Documented participation in a formal, active physical therapy program or through a Blue Cross of Idaho Spine Center of Excellence.
§ Optimized pharmacologic therapy which includes (unless otherwise contraindicated)
o Anti-inflammatory medications maximized at prescription strength and frequency AND
o Non-narcotic analgesics maximized at prescription strength and frequency (e.g. acetaminophen 1gram up to 4 times a day)
o Neuropathic, muscle relaxant and/or limited use of opioids as deemed appropriate
§ Other conservative measures which may not be substituted for those above but which may be used adjunctively can include:
o A home exercise program
o Activity modification
o Facet or epidural injections
o Other measures
§ Persistent, debilitating pain on a daily basis due to radicular symptoms as defined above AND
§ Presence of neurological abnormalities (e.g., reflex change, sensory loss, weakness) on examination that correspond to the specific affected nerve root(s)
3. Spinal Stenosis
a. Surgery may be medically necessary when all of the following criteria are met:
§ All other reasonable sources of pain have been ruled out; AND
§ Member has failed at least 12 weeks of conservative therapy including:
o Interventional procedures such as ESI
o Optimized pharmacologic therapies
o Physical therapies
§ Persistent, debilitating pain on a daily basis as defined above due to spinal stenosis AND
§ Presence of neurologic signs and/or symptoms related to spinal stenosis
· Imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, interpretations by the radiologist will supersede.
· Imaging reports must show nerve root or spinal cord compression that correlates with subjective and objective findings. Acceptable imaging modalities are CT scan, MRI and myelogram.
· Discography results will not be used as a determining factor of medical necessity for any requested procedures. Use is not endorsed.
o Discography to evaluate back pain is controversial. Results are of questionable value. There are potential associated risks. This position is based on several studies. The performance of discography requires that both an abnormal disc and a healthy disc (control disc) be injected to assess reproduction of pain.
o The use of discography to make a diagnosis of discogenic pain was not validated in a recent study. “A positive discography was not highly predictive (PPV 50 to 60% in its use in very well defined patient populations) in identifying bona fide isolated intradiscal lesions primarily causing chronic serious LBP.” The false positive rate is 40%.
o A recent study showed that small bore needle puncture and limited pressure injection can cause an increase in the progression of degenerative findings. The discography group had frequent and greater degenerative findings of herniation, end plate changes, disc grade progression and annular fissures as compared to a well matched control group. Objective measures of disc height loss and loss of disc signal were seen after the annular puncture and injection.
o The American Pain Society Clinical Practice Guideline states that in patients with chronic, non-radicular low back pain, provocative discography is not recommended as a procedure for diagnosing low back pain (Strong Recommendation, moderate quality evidence) Chou et al.
The following sole indications for discectomy, laminectomy and hemilaminectomy are considered Not Medically Necessary:
· Signs and symptoms with no correlation to imaging
· Annular tears
· Disk bulge with no neural impingement or cord compression on imaging
· Concordant Discography
Regarding Medicare Advantage Patients:
Medicare Advantage follows the medical policies of the Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for the Medicare contractors in the state of Idaho.
If no NCD or Idaho LCD policy exists on the topic, it defaults to Blue Cross of Idaho commercial policy for medical necessity determination.
North American Spine Society (www.spine.org) accessed 1/2013
NASS Clinical Guidelines –Degenerative Spinal Stenosis
There is insufficient evidence to make a recommendation for or against the use of physical therapy or exercise as stand-alone treatments for degenerative lumbar spinal stenosis. In the absence of reliable evidence, it is the work group’s opinion that a limited course of active physical therapy is an option for patients with lumbar spinal stenosis.
Grade of Recommendation: I
Interlaminar epidural steroid injections are suggested to provide short term (two weeks to six months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term (21.5-24 months) efficacy.
Grade of Recommendation: B
A multiple injection regimen of radiographically-guided transforaminal epidural steroid injection or caudal injections is suggested to produce medium-term (3-36 months) relief of pain in patients with radiculopathy or neurogenic intermittent claudication (NIC) from lumbar spinal stenosis.
Grade of Recommendation: C
Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis.
Grade of Recommendation: B
Medical/interventional treatment may be considered for patients with moderate symptoms of lumbar spinal stenosis.
Grade of Recommendation: C
- (McGill, C.M. Industrial back problems. Journal of Occupational Medicine, 10, 1740-1748) 1968.
- Peul, W.C. et al. Surgery vs. prolonged conservative treatment for sciatica. NEJM 2007; 356:2245-56
- Vrooman PCAS, de Krom MCTFM, Knotteraus JA, Predicting the outcome of sciatica at short-term follow-up. Br J. Gen Pract 2002;52:119-23
- Carragee, Eugene J. et al. 2009 ISSLS Prize Winner: Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc: A Ten-year Matched Cohort Study. Spine, 2009;34(21): 2338-2345.
- Carragee, Eugene J. et al. A Gold Standard Evaluation of the “Discogenic Pain” Diagnosis as Determined by Provocative Discography. Spine 2006; 31(18):2115-2123.
- Jacobs WC. et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. European Spine Journal 2011; April
- Weinstein JN. Et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA; 2006; 296:22441-2450.
- Peul W.C. et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008 336(7657):1355-8.
- Carragee EJ.et al. Is lumbar discography a determinate of discogenic low back pain: provocative discography reconsidered. Current Rev Pain 2000; 4(4)301-8.
- Carragee EJ et al. False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine 1999 Dec 1;24(23):2452-7.
- Carragee EJ et al. Provoactive discography in volunteer subjects with mild persistent low back pain. Spine J. 2002 Jan-Feb;2(1)25-34.
- Munter FM, Wasserman BA, Wu HM, Yousem DM. Serial MR Imaging of Annular Tears in Lumbar Intervertebral Disks. AJNR Am J Neuroradiol 2002; 23:1105.
- Slipman CW, Patel RK, Zhang L, et al. Side of symptomatic annular tear and site of low back pain: is there a correlation? Spine (Phila Pa 1976) 2001; 26:E165.
- Jarvik JJ, Hollingworth W, Heagerty P, et al. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine (Phila Pa 1976) 2001; 26:1158.
- Jarvik JG, Hollingworth W, Heagerty PJ, et al. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976) 2005; 30:1541.
- Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S. Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis. Spine. 2009;34(10):985-9.