Lumbar Spinal Stenosis Clinical Guidelines for Medical Necessity Review Version: 4.0 Effective Date: November 13, 2020 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Important Notices Notices & ​Disclaimers: GUIDELINES SOLELY FOR COHERE’S USE IN PERFORMING MEDICAL NECESSITY REVIEWS AND ARE NOT INTENDED TO INFORM OR ALTER CLINICAL DECISION MAKING OF END USERS. Cohere Health, Inc. (“​Cohere​”) has published these clinical guidelines to determine medical necessity of services (the “​Guidelines​”) for informational purposes only, and solely for use by Cohere’s authorized “​End Users​”. These Guidelines (and any attachments or linked third party content) are not intended to be a substitute for medical advice, diagnosis, or treatment directed by an appropriately licensed healthcare professional. These Guidelines are not in any way intended to support clinical decision making of any kind; their sole purpose and intended use is to summarize certain criteria Cohere may use when reviewing the medical necessity of any service requests submitted to Cohere by End Users. Always seek the advice of a qualified healthcare professional regarding any medical questions, treatment decisions, or other clinical guidance. ​The Guidelines, including any attachments or linked content, are subject to change at any time without notice. ©2020 Cohere Health, Inc. All Rights Reserved. Other ​Notices: CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Guideline ​Information​: Specialty Area:​ Diseases of the musculoskeletal system and connective tissue (M00-M99) CarePath Group:​ Spine CarePath Name: ​Lumbar Spinal Stenosis​ ​(M48) Physician author: ​Mandy Armitage, MD (Sports Medicine) Peer reviewed by: ​Adrian Thomas, MD (Orthopedic Spine Surgeon) Literature review current through​: ​June 22, 2020 Document last updated:​ ​November 13, 2020 Type:​ [​X​] Adult (18+ yo) | [_] Pediatric (0-17yo) Page 2 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Table of Contents Important Notices 2 Care Path Overview 7 Care Path Clinical Discussion 7 Key Information 7 Definitions 8 Care Path Diagnostic Criteria 10 Disease Classification 10 ICD-10 Codes Associated with Classification 10 Presentation and Etiology 12 Causes and Risk Factors 12 Clinical Presentation 12 Typical Physical Exam Findings 13 Typical Diagnostic Findings 13 CarePath Services & Medical Necessity Criteria 14 Conservative Therapy 14 Service: Physical Therapy 14 General Guidelines 14 Medical Necessity Criteria 14 Indications 14 Non-Indications 14 Applicable CMS Medicare NCDs & LCDs 15 Site of Service Criteria 15 Procedure Codes (HCPCS/CPT) 15 Advanced Imaging 20 Service: Magnetic Resonance Imaging (MRI) 20 General Guidelines 20 Medical Necessity Criteria 20 Indications 20 Non-Indications 20 Applicable CMS Medicare NCDs & LCDs 21 Site of Service Criteria 21 Procedure Codes (HCPCS/CPT) 21 Service: Computed Tomography (CT) or CT Myelogram (CTM) 22 General Guidelines 22 Medical Necessity Criteria 22 Page 3 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. 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Indications 22 Non-Indications 22 Applicable CMS Medicare NCDs & LCDs 22 Site of Service Criteria 23 Procedure Codes (HCPCS/CPT) 23 Non-Surgical Management 24 Service: Epidural Steroid Injections 24 General Guidelines 24 Medical Necessity Criteria 24 Indications 24 Non-Indications 13 24 Applicable CMS Medicare NCDs & LCDs 25 Site of Service Criteria 25 Procedure Codes (HCPCS/CPT) 25 Surgical Management 27 Service: Lumbar Decompression without Fusion 27 General Guidelines 27 Medical Necessity Criteria 27 Indications 27 Non-Indications 28 Applicable CMS Medicare NCDs & LCDs 28 Site of Service Criteria 28 Procedure Codes (HCPCS/CPT) 28 Service: Lumbar Decompression with Fusion 34 General Guidelines 34 Medical Necessity Criteria 34 Indications 34 Non-Indications 34 Applicable CMS Medicare NCDs & LCDs 34 Site of Service Criteria 35 Procedure Codes (HCPCS/CPT) 35 Service: Interspinous/Interlaminar Spacer Implantation 39 General Guidelines 39 Medical Necessity Criteria 39 Indications 39 Non-Indications 39 Applicable CMS Medicare NCDs & LCDs 40 Page 4 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. 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Site of Service Criteria 40 Procedure Codes (HCPCS/CPT) 40 Surgical Risk Factors 42 Post-Operative Care 45 Service: Physical Therapy 45 General Guidelines 45 Medical Necessity Criteria 45 Indications 45 Non-Indications 45 Applicable CMS Medicare NCDs & LCDs 45 Site of Service Criteria 45 Procedure Codes (HCPCS/CPT) 45 Service: Home Health Care 50 General Guidelines 50 Medical Necessity Criteria 50 Indications 50 Non-Indications 50 Applicable CMS Medicare NCDs & LCDs 50 Site of Service Criteria 50 Procedure Codes (HCPCS/CPT) 50 Service: Inpatient Rehabilitation 52 General Guidelines 52 Medical Necessity Criteria 52 Indications 52 Non-Indications 52 Applicable CMS Medicare NCDs & LCDs 52 Site of Service Criteria 52 Procedure Codes (HCPCS/CPT) 53 Service: Skilled Nursing Facility 54 General Guidelines 54 Medical Necessity Criteria 54 Indications 54 Non-Indications 54 Applicable CMS Medicare NCDs & LCDs 54 Site of Service Criteria 54 Procedure Codes (HCPCS/CPT) 54 Page 5 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. References 57 Page 6 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Care Path Overview Care Path Clinical Discussion The North American Spine Society describes degenerative ​lumbar spinal stenosis​ as “a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal 1​ canal.”​ The presentation involves neurogenic claudication which can manifest as a variable clinical picture, but classically patients complain of symptoms made worse with walking or upright activity and improved with resting in a seated or forward 1​, ​2 flexed position.​ Stenosis may be due to herniated disc, spondylosis, or spondylolisthesis. Experts agree that the natural history of mild to moderate stenosis is favorable in one-third to one-half of patients. However, in the patients who do not experience self-resolution of symptoms, have moderate to severe or progressive symptoms, or who have a complex spinal health history, further evaluation and intervention may 1 be warranted. Magnetic resonance imaging (MRI) is the imaging modality of choice.​ Nonsurgical treatment options include exercise and the possibility of epidural steroid injection, and surgical intervention involves decompression without fusion (in the 1​–​3 absence of instability).​ The information contained herein gives a general overview of the pathway of this specific diagnosis, beginning with initial presentation, recommended assessments, and treatment options as supported by the medical literature and existing guidelines. It should be noted that the care of patients with spinal health problems is complex. The information below is meant to support clinical decision making in adult patients. It is not necessarily applicable to every case, as the entire clinical picture (including comorbidities, spinal health history, etc.) should be considered. 1 Case-by-case treatment decisions are encouraged.​ Key Information ● 6 Lumbar spinal stenosis is a common cause of low back pain and leg pain.​ ● 7 Approximately 400,000 Americans suffer from lumbar spinal stenosis.​ ○ 6 Spinal stenosis most often occurs in adults >60 years of age.​ ● First-line treatment of lumbar spinal stenosis is non-surgical management that 6 focuses on restoring function and relieving pain.​ ○ Typical non-surgical treatments include physical therapy, anti-inflammatory medications, and epidural steroid injections. ○ Chiropractic manipulation can help with some of the pain although 6 manipulation of spine can worsen symptoms or cause other injuries.​ ● It is appropriate to consider surgical management of lumbar spinal stenosis if non-surgical management has not relieved symptoms and the patient has activity limitations due to pain and weakness. ○ Decompression is the preferred surgical technique when there is no spinal instability, spinal deformities or vertebral destruction. Page 7 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Definitions ● Straight leg raise test ​is a neurological maneuver in which an examiner gently raises a supine patient’s leg by flexing the hip with the knee in full extension. A positive result occurs when the patient experiences pain along the lower limb in the same distribution of the lower radicular nerve roots, or when pain is elicited by lower limb flexion in an angle 5 >45°.​ Page 8 of 57 Lumbar Spinal Stenosis (v4.0) © 2020 Cohere Health, Inc. All Rights Reserved. Labral Spinal Stenosis What is a “Cohere Care Path”? These Care Paths organize the services typically considered most clinically optimal and likely to be automatically approved. These service recommendations also include the suggested sequencing and quantity or frequency determined clinically appropriate and medically necessary for the management of most patient care scenarios in this Care Path’s diagnostic cohort. Non-Surgical Surgical ManagementManagement Conservative Anti-inflammatory or Pain Management AND Therapy PA,★ Management Physical Therapy Non Diagnostics - Radiography Surgical PA,★ Advanced Magnetic Resonance Imaging (MRI) OR Imaging