Utilization Review Checklist
Lumbar Disc Herniation with Radiculopathy
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 63030, 63042, 63047, 62287, 22558, 22630. ICD-10 M51.16, M51.17, M54.16, M54.17, G55.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Presumptive Diagnosis
Required
Radicular pain syndrome with current dermatomal pain and/or numbness, or myotomal muscle weakness, all consistent with a herniated disc
“radicular pain syndrome with current dermatomal pain and/or numbness, or myotomal muscle weakness all consistent with a herniated disc” — p. 167
Confirmatory Diagnosis
Required
MRI, or CT with or without myelography, confirming persisting nerve root compression at the level and on the side predicted by the history and clinical examination
“imaging findings by MRI, or CT with or without myelography that confirm persisting nerve root compression at the level and on the side predicted by the history and clinical examination” — p. 167
Conservative Care
Any one of the following
Continued significant pain and functional limitation after 4 to 6 weeks of time and appropriate non-operative therapy that usually includes NSAID(s) — at least 4 weeks
“continued significant pain and functional limitation after 4 to 6 weeks of time and appropriate non-operative therapy that usually includes NSAID(s)” — p. 167
OR
Progressive neurological deficit (a separate indication — the trial of therapy does not apply)
“Progressive neurological deficits are considered a separate indication.” — p. 167
Procedures — the guideline treats each separately
Lumbar discectomy — open, microdiscectomy, or endoscopic
Moderately Recommended. Open discectomy, microdiscectomy, and endoscopic discectomy are all potentially appropriate ways to perform discectomy.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence high · p. 167
Indications — required:
All three indications above are documented
“Indications – All of the following should be present:” — p. 167
The guideline is explicit that open discectomy, microdiscectomy and endoscopic discectomy are all appropriate ways to perform the operation and leaves the choice to the surgeon and patient. Do not argue the approach; document the three indications.
Spinal fusion at the time of a third discectomy on the same disc
Recommended. Spinal fusion is recommended as an option at the time of discectomy if a patient is having the third lumbar discectomy on the same disc.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low · p. 172
Indications — required:
This is the third lumbar discectomy on the same disc, and the indications for that third discectomy are met
“Indications – Meeting indications for a third discectomy on the same disc.” — p. 172
Supported only where this is the THIRD discectomy on the SAME disc and the indications for that third discectomy are themselves met. State the number of prior discectomies and the level. The evidence grade is Insufficient (I) with Low confidence, so expect scrutiny.
Artificial disc replacement for subacute or chronic radiculopathy or myelopathy
No Recommendation. There is no recommendation for artificial disc replacement as a treatment for subacute or chronic radiculopathy or myelopathy.
Strength of Evidence — No Recommendation, Evidence (I) · confidence low · p. 176
Indications — required:
The guideline makes no recommendation for or against this procedure
“There is no recommendation for artificial disc replacement as a treatment for subacute or chronic radiculopathy or myelopathy.” — p. 176
The guideline makes NO recommendation either way here — it neither supports nor advises against. That is not the same as approval and not the same as denial. Expect to justify the request on grounds the guideline does not supply.
Discectomy for low back pain WITHOUT radiculopathy
Moderately Not Recommended. Discectomy is moderately not recommended for treatment of acute, subacute, or chronic low back pain without radiculopathy.
Strength of Evidence — Moderately Not Recommended, Evidence (B) · confidence high · p. 167
Indications — required:
The guideline moderately advises against discectomy where there is no radiculopathy
“Discectomy is moderately not recommended for treatment of acute, subacute, or chronic low back pain without radiculopathy.” — p. 167
Moderately NOT recommended at High confidence. If the patient has no radicular findings, the guideline advises against discectomy for acute, subacute or chronic low back pain.
Percutaneous discectomy (nucleoplasty), laser discectomy, or disc coblation
Not Recommended. Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy are not recommended for treatment for any back or radicular pain syndrome.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence low · p. 167
Indications — required:
The guideline advises against these for any back or radicular pain syndrome
“Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy are not recommended for treatment for any back or radicular pain syndrome.” — p. 167
Not recommended for ANY back or radicular pain syndrome. The guideline notes these are indirect procedures with limited access to the disc contents.
Lumbar fusion to treat radiculopathy from disc herniation
Not Recommended. Lumbar fusion is not recommended to treat radiculopathy from disc herniation or for most patients with chronic low back pain after lumbar discectomy.
Strength of Evidence — Not Recommended, Insufficient Evidence (I) · confidence moderate · p. 172
Indications — required:
The guideline advises against fusion for this indication; the foraminal-herniation exception is rare and not reduced to criteria
“Exceptions are rare but include large foraminal herniations with need to remove the facet joint to access the disc.” — p. 172
Not recommended. The guideline allows a rare exception — large foraminal herniations needing facet removal to reach the disc — which it does not reduce to criteria. If that is the case, say so explicitly and expect it to be read as an exception, not a rule.