This version of the policy will become effective on 06/15/2020. Description section was updated. Physiatry consultation requirement was added to the lumbar portion of the policy criteria section.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
For individuals who have lumbar spinal stenosis and spinal cord or nerve root compression who receive lumbar laminectomy, the evidence includes randomized controlled trials (RCTs) and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. In patients with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative “usual care” in individuals with spinal stenosis who do not improve after eight weeks of conservative treatment. The superiority of laminectomy is sustained through up to eight years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected patients have similar outcomes at two years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options.The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have cervical spinal stenosis and spinal cord or nerve root compression who receive cervical laminectomy, the evidence includes RCTs and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. There is a lack of high-quality, comparative evidence for this indication, although what evidence there is offers outcomes similar to those for lumbar spinal stenosis. Given the parallels between cervical laminectomy and lumbar laminectomy, a chain of evidence can be developed that the benefit reported for lumbar laminectomy supports a benefit for cervical laminectomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive cervical, thoracic, or lumbar laminectomy, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Most case series are small and retrospective. They have reported that most patients with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The evidence is insufficient to determine the effects of the technology on health outcomes.
The current standard of care, clinical input, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for patients with space-occupying lesions of the spinal cord.
63003, 63016, 63046, 63271, 63276, 63281, 63286
63005, 63012, 63017, 63047, 63048, 63185, 63190, 63200, 63267, 63272, 63277, 63282, 63290