Clinical UM Guideline


Subject:  Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
Guideline #:  CG-SURG-38Current Effective Date:  08/18/2014
Status:RevisedLast Review Date:  08/14/2014

Description

This document addresses laminectomy, hemi-laminectomy, laminotomy and discectomy as a means to surgically manage various lumbar conditions.

A lumbar laminectomy is a surgical procedure which involves the removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra.  The procedure is performed to relieve pressure on the nerve roots and spinal cord.  The most common reason for performing a laminectomy is to treat spinal stenosis which is a chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration.  If only one side is removed, it is called a hemilaminectomy.  It is not uncommon for a laminectomy to be performed in combination with other surgical procedures such as discectomy (diskectomy), foraminotomy, spinal fusion or excision of an intraspinal tumor or lesion.  In most cases a laminectomy is performed as an elective procedure rather than as emergency surgery.

For information regarding other spinal procedures, see:

Clinical Indications

Medically Necessary: 

Note: When procedure is performed using a percutaneous or endoscopic approach (as opposed to an open approach with direct visualization), refer to SURG.00071 Percutaneous and Endoscopic Spinal Surgery.

Lumbar laminectomy, hemilaminectomy, laminotomy (for unilateral symptoms), and/or discectomy is considered medically necessary when at least one of the following criteria is met:

  1. Conus medullaris syndrome (spinal cord compression) confirmed by appropriate imaging studies with severe or progressive neurologic deficits consistent with spinal cord compression (for example, fecal or urinary incontinence); OR
  2. Cauda equina syndrome with neurologic deficits (bowel or bladder dysfunction, saddle anesthesia, bilateral neurologic abnormalities of the lower extremities) confirmed by physical examination and appropriate imaging studies; OR
  3. Lumbar spinal stenosis and/or foraminal stenosis confirmed by appropriate imaging studies, with either:
    1. severe and progressive symptoms of pain or neurogenic claudication (buttock or leg) unresponsive to at least 6 weeks of conservative nonoperative therapy; or
    2. significant motor deficit preventing ambulation; OR
  4. Lumbar herniated intervertebral disc with nerve root compression confirmed by appropriate imaging studies and the following additional criteria are met:
    1. Radicular pain with physical findings of nerve compression (for example, absent lower extremity reflex or loss of sensation in dermatomal distribution) or alternative clinical findings consistent with radiculopathy; and
    2. All other reasonable sources of pain have been ruled out; and
    3. Findings on imaging correspond to the clinical findings and neurological examination; and
    4. Symptoms are interfering with either:
      1. functional activities of daily living and persist despite at least 6 weeks of conservative nonoperative therapy; or
      2. are associated with significant or progressive motor deficits; OR
  5. When performed with dorsal rhizotomy as a treatment for spasticity (for example, cerebral palsy); OR
  6. When performed with biopsy or excision when signs or symptoms indicative of lumbar disease (for example, pain, motor weakness) and imaging suggests tumor or metastatic neoplasm, an infectious process (for example, epidural abscess), arteriovenous malformation, malignant or non-malignant mass; OR
  7. Acute fracture causing symptomatic nerve root compression.

Note: Conservative non-operative therapy consists of an appropriate combination of medication (for example, Non-Steroidal Anti-Inflammatory Drugs [NSAIDs], analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual's specific presentation, physical findings and imaging results.

Not Medically Necessary: 

Lumbar laminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar hemilaminectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar laminotomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Lumbar discectomy is considered not medically necessary when criteria above are not met and for all other indications not listed above as medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
63005Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis) 1 or 2 vertebral segments; lumbar, except for spondylolisthesis
63012Laminectomy with removal of abnormal facets and/or pars interarticularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)
63017Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar
63030Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
63035Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar [when specified as lumbar]
63042Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar
63044Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; each additional lumbar interspace
63047Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
63048Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar [when specified as lumbar]
63056Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)
63057Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar [when specified as lumbar]
63185Laminectomy with rhizotomy; 1 or 2 segments [when specified as lumbar]
63190Laminectomy with rhizotomy; more than 2 segments [when specified as lumbar]
63200Laminectomy, with release of tethered spinal cord, lumbar
63252Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar
63267Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
63272Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar
63277Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar
63282Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar
63287Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar
63290Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level [when specified as lumbar]
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
 For the following procedures when specified as lumbar:
03.02Reopening of laminectomy site
03.09Other exploration and decompression of spinal canal
03.1Division of intraspinal nerve root
03.4Excision or destruction of lesion of spinal cord or spinal meninges
03.6Lysis of adhesions of spinal cord and nerve roots
80.50Excision or destruction of intervertebral disc, unspecified
80.51Excision of intervertebral disc
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
170.2Malignant neoplasm of vertebral column, excluding sacrum and coccyx
192.2Malignant neoplasm of spinal cord (cauda equina)
198.3Secondary malignant neoplasm of brain and spinal cord
213.2Benign neoplasm of vertebral column, excluding sacrum and coccyx
225.3-225.4Benign neoplasm of spinal cord (cauda equina), spinal meninges
237.5-237.6Neoplasm of uncertain behavior of brain and spinal cord, meninges
324.1Intraspinal abscess
343.0-343.9Infantile cerebral palsy
344.1Paraplegia
344.60-344.61Cauda equina syndrome
564.81Neurogenic bowel
720.0Ankylosing spondylitis
721.3Lumbosacral spondylosis without myelopathy
721.42Spondylosis with myelopathy, lumbar region
722.10Displacement of lumbar intervertebral disc without myelopathy
722.32Schmorl's nodes, lumbar region
722.52Degeneration of lumbar or lumbosacral intervertebral disc
722.73Intervertebral disc disorder with myelopathy, lumbar region
722.83Postlaminectomy syndrome, lumbar region
722.93Other and unspecified disc disorder, lumbar region
724.02-724.03Spinal stenosis, lumbar region
724.2Lumbago
724.3Sciatica
724.4Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5Backache, unspecified
738.4Acquired spondylolisthesis
742.9Unspecified anomaly of brain, spinal cord, and nervous system [arteriovenous malformation]
756.11-756.12Other congenital anomalies; spondylolysis, lumbosacral region, spondylolisthesis
805.4Fracture of vertebral column without mention of spinal cord injury, lumbar, closed
805.5Fracture of vertebral column without mention of spinal cord injury, lumbar, open
953.2Injury to nerve roots and spinal plexus; lumbar root
  
ICD-10 Procedure[For dates of service on or after 10/01/2015]
008Y0ZZDivision of lumbar spinal cord, open approach
008Y4ZZDivision of lumbar spinal cord, percutaneous endoscopic approach
009Y00ZDrainage of lumbar spinal cord with drainage device, open approach
009Y0ZZDrainage of lumbar spinal cord, open approach
009Y40ZDrainage of lumbar spinal cord with drainage device, percutaneous endoscopic approach
009Y4ZZDrainage of lumbar spinal cord, percutaneous endoscopic approach
00BY0ZZExcision of lumbar spinal cord, open approach
00BY4ZZExcision of lumbar spinal cord, percutaneous endoscopic approach
00NY0ZZRelease lumbar spinal cord, open approach
00NY4ZZRelease lumbar spinal cord, percutaneous endoscopic approach
018B0ZZDivision of lumbar nerve, open approach
018B4ZZDivision of lumbar nerve, percutaneous endoscopic approach
0SB00ZZExcision of lumbar vertebral joint, open approach
0SB04ZZExcision of lumbar vertebral joint, percutaneous endoscopic approach
0SB20ZZExcision of lumbar vertebral disc, open approach
0SB24ZZExcision of lumbar vertebral disc, percutaneous endoscopic approach
0SB30ZZExcision of lumbosacral joint, open approach
0SB34ZZExcision of lumbosacral joint, percutaneous endoscopic approach
0SB40ZZExcision of lumbosacral disc, open approach
0SB44ZZExcision of lumbosacral disc, percutaneous endoscopic approach
0SN00ZZRelease lumbar vertebral joint, open approach
0SN04ZZRelease lumbar vertebral joint, percutaneous endoscopic approach
0SN20ZZRelease lumbar vertebral disc, open approach
0SN24ZZRelease lumbar vertebral disc, percutaneous endoscopic approach
0SN30ZZRelease lumbosacral joint, open approach
0SN34ZZRelease lumbosacral joint, percutaneous endoscopic approach
0SN40ZZRelease lumbosacral disc, open approach
0SN44ZZRelease lumbosacral disc, percutaneous endoscopic approach
0ST20ZZResection of lumbar vertebral disc, open approach
0ST40ZZResection of lumbosacral disc, open approach
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
C41.2Malignant neoplasm of vertebral column
C70.1Malignant neoplasm of spinal meninges
C72.0-C72.1Malignant neoplasm of spinal cord, cauda equina
C79.49Secondary malignant neoplasm of other parts of nervous system
D16.6Benign neoplasm of vertebral column
D32.1Benign neoplasm of spinal meninges
D33.4Benign neoplasm of spinal cord
D42.1Neoplasm of uncertain behavior of spinal meninges
D43.4Neoplasm of uncertain behavior of spinal cord
G06.1Intraspinal abscess and granuloma
G80.0-G80.9Cerebral palsy
G82.20-G82.22Paraplegia
G83.4Cauda equina syndrome
K59.2Neurogenic bowel, not elsewhere classified
M08.1Juvenile ankylosing spondylitis
M43.06-M43.07Spondylolysis, lumbar/lumbosacral regions
M43.16-M43.17Spondylolisthesis, lumbar/lumbosacral regions
M45.6-M45.7Ankylosing spondylitis, lumbar/lumbosacral regions
M47.16-M47.17Other spondylosis with myelopathy, lumbar/lumbosacral regions
M47.26-M47.27Other spondylosis with radiculopathy, lumbar/lumbosacral regions
M47.816-M47.817Spondylosis without myelopathy or radiculopathy, lumbar/lumbosacral regions
M47.896-M47.897Other spondylosis, lumbar/lumbosacral regions
M48.06-M48.07Spinal stenosis, lumbar/lumbosacral regions
M48.36-M48.37Traumatic spondylopathy, lumbar/lumbosacral regions
M48.8X6-M48.8X7Other specified spondylopathies, lumbar/lumbosacral regions
M51.06-M51.07Intervertebral disc disorders with myelopathy, lumbar/lumbosacral regions
M51.16-M51.17Intervertebral disc disorders with radiculopathy, lumbar/lumbosacral regions
M51.26-M51.27Other intervertebral disc displacement, lumbar/lumbosacral regions
M51.36-M51.37Other intervertebral disc degeneration, lumbar/lumbosacral regions
M51.46-M51.47Schmorl's nodes, lumbar/lumbosacral regions
M51.86-M51.87Other intervertebral disc disorders, lumbar/lumbosacral regions
M54.16-M54.17Radiculopathy, lumbar/lumbosacral regions
M54.30-M54.32Sciatica
M54.40-M54.42Lumbago with sciatica
M54.5Low back pain
M54.9Dorsalgia, unspecified
M96.1Postlaminectomy syndrome, not elsewhere classified
Q27.39Arteriovenous malformation, other site
Q76.2Congenital spondylolisthesis
S32.000A-S32.059SFracture of lumbar vertebra
S34.21XA-S34.21XSInjury of nerve root of lumbar spine
  
Discussion/General Information

Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy 

Lumbar laminectomy, hemilaminectomy, laminotomy and discectomy are established surgical options for several conditions when symptoms persist despite noninvasive treatment (when conservative management is appropriate) or as first line treatment for certain emergencies.  Several specialty associations/societies have published guidelines which provide criteria for when lumbar laminectomy, hemilaminectomy, laminotomy and/or discectomy is considered an appropriate surgical intervention.  There are also numerous peer-reviewed articles that discuss the pros and cons of these procedures.

As with all surgical procedures, lumbar surgery is not without risk.  It has been reported that dural tears occur in approximately 10% of individuals undergoing laminectomy, and neurologic injuries may occur in about 2.5%.  The American Pain Society (APS) guidelines on interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain recommended that clinicians discuss the risks and benefits of surgery as an "Option" (that is, strong recommendation, high-quality evidence).  It is further recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).

The North American Spine Society (NASS) "Coverage Policy Recommendations" provide clinical indications for several spine procedures including, but not limited to lumbar laminotomy and lumbar discectomy.  According to information on the NASS website, the Coverage Policy Recommendations were created using "an evidence-based approach to spinal care when possible.  In the absence of strict evidence-based criteria, policies reflect the multidisciplinary and non-conflicted experience and expertise of the authors in order to reflect reasonable standard practice indications in the United States"  The authors also state that the coverage recommendations are not representative of a "standard of care" and should not be viewed as "fixed treatment protocols" (NASS, 2014).

Low back Pain

The National Institute for Clinical Excellence's (NICE) guidance on early management of people with non-specific low back pain (LBP) indicates that it is important for practitioners to assist individuals with persistent non-specific LBP self-manage their condition.  The guidance recommends that one of the following treatment options be offered to individuals with LBP: (1) An exercise program; (2) A course of manual therapy (i.e., spinal manipulation, spinal mobilization, massage); (3) A course of acupuncture, and pharmacological therapy; or (4) Referral to a combined physical and psychological treatment program may be appropriate for individuals who have received at least one less intensive treatment and have high disability and/or significant psychological distress.  With regards to invasive procedures, the authors caution that:

Robust trials, including health economic evaluations, should be carried out to determine the effectiveness and cost effectiveness of invasive procedures – in particular, facet joint injections and radiofrequency lesioning.  These should include the development of specific criteria for patient selection and a comparison with non-invasive therapies (2009).

The APS recommends that in instances where conservative management fails to relieve symptoms of radiculopathy and there is strong evidence of dysfunction of a specific nerve root confirmed at the corresponding level by CT or MRI, further evaluation and more invasive treatment, including spine surgery, may be proposed as a treatment option (Chou, 2009).

According to the Washington State Department of Labor and Industries guidelines which provide criteria for single lumbar nerve root entrapment, lumbar laminectomy is appropriate for individuals who failed to respond to treatment after a minimum of four weeks of conservative therapy and have both objective and subjective findings of lumbar nerve root entrapment (Washington State, 1999).

Lumbar disc (herniated intervertebral disc) 

Most instances of lumbar disc herniations will respond positively to conservative management and will not require surgical treatment.  However, some individuals may have severe, unremitting pain that requires more immediate intervention.

The Spine Patient Outcomes Research Trial (SPORT) was funded by the National Institutes of Health (NIH) to study the outcomes from surgical and nonsurgical management of three conditions: intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis.  Both surgical and nonsurgical care of intervertebral disc herniation resulted in significant improvement in symptoms of low back and leg pain.  However, the treatment effect of surgery for intervertebral disc herniation was less than that seen in individuals with degenerative spondylolisthesis and lumbar spinal stenosis.  The preliminary four-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009).

According to the APS, decompressive laminectomy may be an acceptable option for individuals experiencing disabling and persistent leg pain due to spinal stenosis, either with or without degenerative spondylolisthesis.  The APS reports that decompressive laminectomy is associated with moderate benefits compared to nonsurgical therapy through 1 to 2 years, though the effects of the procedure appear to diminish with long-term follow-up.  Although individuals on average do not worsen without surgery, improvements are less than those observed in individuals with radiculopathy due to herniated lumbar disc.  Their guidelines indicate there is insufficient evidence to determine if laminectomy with fusion is more effective than laminectomy without fusion.  The authors recommended that shared decision-making regarding surgery include a specific discussion about moderate/average benefits, which appear to decrease over time in affected individuals who undergo surgery (Chou, 2009).

Lumbar spinal stenosis and/or foraminal stenosis 

NASS (2011) published evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spinal stenosis.  The NASS found that in the absence of evidence for or against any specific treatment, it is the work group's recommendation that medical/interventional treatment be considered for individuals with mild symptoms of lumbar spinal stenosis.  The group also issued a consensus statement indicating that individuals with mild symptoms are generally not considered surgical candidates (Kreiner, 2011).

As mentioned above, the SPORT trial explored the outcomes from surgical and nonsurgical management of intervertebral disc herniation, degenerative spondylolisthesis, and lumbar spinal stenosis.  The preliminary four-year outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).

Lumbar spondylolisthesis 

According to NASS evidence-based guidelines on the diagnosis and treatment of degenerative lumbar spondylolisthesis, the purpose of the guidelines is to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spondylolisthesis.  The group assigned a "B" rating to the consensus statement that surgery be recommended for individuals with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.  The group also issued a statement that there is insufficient evidence to support the use of direct or indirect surgical decompression for the treatment of individuals with symptomatic spinal stenosis associated with low grade degenerative lumbar spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment (Watters, 2008).

According to the SPORT trial investigation (see above), the outcomes data demonstrated more significant degrees of improvement in pain levels and function with surgical versus nonsurgical treatment in the chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis (Asghar, 2012; Weinstein, 2006a; Weinstein, 2006b; Weinstein, 2007; Weinstein, 2009; Weinstein, 2010).

Definitions

Cauda equina (horse's tail) syndrome: A condition which results from the compression of multiple dorsal and ventral nerve roots in the lumbar spinal canal, usually as a result of a large central herniated disc.

Discectomy: The partial or complete removal of an intervertebral disc.

Hemilaminectomy: A surgical procedure in which the lamina is removed on one side of the vertebrae.

Herniated disc: A condition in which a portion of the nucleus pulposus extends through the annulus (the outer disc layers). Herniated discs may additionally be classified as: contained (there is still a retained thin outer layer of annulus or ligament), extruded (the nuclear material extends into the spinal canal) or sequestrated (when a herniated fragment migrates away from the disc).

Lamina: The part of the vertebra that forms the roof of the spinal canal.

Laminectomy: A spine operation to remove all or a portion of the roof of the spinal canal; frequently performed to decompress the neural elements.

Laminotomy: A spine operation in which the lamina is partially removed.

Radiculopathy: Any disease of the spinal nerve roots and spinal nerves; radiculopathy is characterized by pain which seems to radiate from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation; causes of radiculopathy include deformities of the discs between the building blocks of the spine (the vertebrae).

Spine anatomy: The spine is divided into three major sections: the cervical (neck), the thoracic (mid-back) and lumbar spine (lower back). These sections are made up of individual bones called vertebrae, which are the primary weight bearing structures of the torso alternating with intervertebral discs.

Spinal stenosis: A chronic narrowing of the spinal canal due to degenerative arthritis and disc degeneration.

Spondylolisthesis: Forward slippage of one vertebral body with impingement upon the adjacent inferior disc.

Vertebrae: Bones that make up the spinal column which surround and protect the spinal cord.

References

Peer Reviewed Publications: 

  1. Asghar FA, Hilibrand AS. The impact of the Spine Patient Outcomes Research Trial (SPORT) results on orthopaedic practice. J Am Acad Orthop Surg. 2012; 20(3):160-166.
  2. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2002; 27(12):1361-1372.
  3. Daffner SD, Hymanson HJ, Wang JC. Cost and use of conservative management of lumbar disc herniation before surgical discectomy. Spine J. 2010; 10(6):463-468.
  4. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009; 91(6):1295-1304.
  5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007; 356(22):2257-2270.
  6. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006a; 296(20):2451-2459.
  7. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010; 35(14):1329-1338.
  8. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs. nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006b; 296(20):2441-2450.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Chou R, Loeser JD, Owens DK, et al.; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009; 34(10):1066-1077.
  2. Kreiner DS, Shaffer WO, Summers J, et al. North American Spine Society (NASS). Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. Revised 2011. Available at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. Accessed on July 13, 2014.
  3. National Institute of Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain (NICE CG88). 2009. Available at: http://www.nice.org.uk/guidance/CG88. Accessed on July 13, 2014.
  4. North American Spine Society (NASS). NASS Coverage Policy Recommendations. Available at: www.spine.org. Accessed on July 13, 2014.
    • Lumbar Discectomy (2014).
    • Lumbar Laminotomy (2014).
  5. Washington State Department of Labor and Industries. Medical Treatment Guidelines. Criteria for entrapment of a single lumbar nerve root. Olympia, WA: Washington State Department of Labor and Industries; 1992. Available at: http: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/SingleLumbarNerveRoot.pdf. Accessed on July 13, 2014.
  6. Watters WC, Bono C, Gilbert T, et al.  North American Spine Society (NASS).  Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2008. Available at: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/Spondylolisthesis.pdf. Accessed on July 13, 2014.
Websites for Additional Information
  1. American Academy of Orthopedic Surgeons (AAOS). Website for relevant information. Last review June 2010. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00348. Accessed on July 13, 2014.
  2. North American Spine Society (NASS). Know your back. Available at: http://www.knowyourback.org/Pages/Default.aspx. Accessed on July 13, 2014.
Index

Lumbar discectomy
Lumbar hemilaminectomy
Lumbar laminectomy
Lumbar laminotomy

History

Status

Date

Action

Reviewed08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review. In the medically necessary criteria, reformatted bullets #3 and #4. "Acute fracture causing symptomatic nerve root compression" added as a medically necessary indication. Coding, Discussion/General Information, References and History sections updated.
Revised02/13/2014MPTAC review. In the Clinical Indications section, the word "back" was removed from criterion #4a. Updated Discussion/General Information and References sections.
New11/14/2013MPTAC review. Initial document development.