According to a new national coverage determination, CMS said Medicare will not reimburse percutaneous image-guided lumbar decompression for lumbar spinal stenosis patients.
CMS officials said spinal stenosis, which occurs when the spinal canal narrows and thus causes lower back pain, is the most common reason for lumbar spine surgery in adults older than 65. It's often the result of normal aging. Complex surgical procedures to treat lumbar spinal stenosis have "increased substantially" over the past several years as well, according to CMS.
Most surgical options to treat lumbar spinal stenosis are laminectomy and spinal fusion. However, percutaneous image-guided lumbar decompression, or PILD, is a newer technique for lumbar spinal stenosis patients. PILD is a minimally invasive procedure conducted via image guidance "without any direct visualization of the surgical area," according to the analysis. PILD is often performed commercially with mild, a technology owned by Vertos Medical.
CMS opened a national coverage analysis of PILD for lumbar spinal stenosis this past April, and after several months of combing through studies and reviewing public comments, the agency concluded the treatment will not be covered by Medicare. CMS cited several reasons:
• Lack of consensus on diagnostic criteria. CMS said since many conditions lead to back pain, it is hard to peg what exactly defines spinal stenosis patients.
• Lack of consensus on the treatment of lumbar spinal stenosis. Laminectomies already exist as a minimally invasive option for lumbar spinal stenosis patients, and CMS said other nonsurgical treatments could be options as well.
• PILD as a treatment. CMS said it is not certain performing spinal surgery with PILD tools is "efficacious" and necessary.
• Analysis of evidence for PILD as a treatment. CMS called available studies on PILD "weak," making it difficult to determine if Medicare patients will benefit from the procedure.
Many Blue Cross Blue Shield subsidiaries, including North Carolina and Tennessee, also consider PILD "investigational" and generally don't provide coverage for it.
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