Utilization Review Checklist
Lumbar Spinal Stenosis with Neurogenic Claudication
Derived from the ACOEM Low Back Disorders Guideline, edition 13 February 2020, as adopted into the California MTUS 23 November 2021. CPT 63047, 63048, 63005, 63012, 22612, 22633. ICD-10 M48.061, M48.062, M48.07, M99.63.
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-type pain involving usually multiple dermatomes with pain and/or numbness, or myotomal muscle weakness, all consistent with the nerve root levels affected
“radicular-type pain involving usually multiple dermatomes with pain and/or numbness, or myotomal muscle weakness all consistent with the nerve root levels affected” — p. 169
Confirmatory Diagnosis
Required
MRI, or CT with or without myelography, confirming spinal stenosis and corroborating the dermatomal and myotomal findings predicted by the history and clinical examination
“imaging findings by MRI, or CT with or without myelography that confirm spinal stenosis and corroborate the dermatomal and myotomal findings predicted by the history and clinical examination” — p. 169
Conservative Care
Any one of the following
Continued significant pain and functional limitation after at least 4 to 6 weeks of appropriate non-operative therapy — at least 4 weeks
“pain and functional limitation after at least 4 to 6 weeks of time and appropriate non-operative therapy that usually includes flexion exercises plus aerobic exercise (walking or cycling), and NSAIDs.” — p. 170
OR
Progressive neurological deficit (a separate indication — the trial of therapy does not apply)
“Progressive neurological deficits are considered a separate indication.” — p. 170
Procedures — the guideline treats each separately
Decompression surgery for spinal stenosis (laminectomy, laminotomy, hemilaminectomy, facetectomy, posterior decompression)
Moderately Recommended. Decompression surgery is moderately recommended as an effective treatment for patients with symptomatic spinal stenosis (neurogenic claudication) that is intractable to conservative management.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence moderate · p. 169
Indications — all of the following:
All three indications above are documented
“Indications – All of the following should be present:” — p. 169
AND
If the patient is elderly with multiple comorbidities, the guideline's caution has been addressed
“Caution is warranted among elderly with multiple comorbidities.” — p. 169
Supported where all three indications are documented. The guideline adds a caution about elderly patients with multiple comorbidities — address comorbidity explicitly if it applies.
Adding lumbar fusion to decompression for stenosis, without proven instability or deformity
Not Recommended. Lumbar fusion is not recommended for treatment of spinal stenosis unless concomitant instability or deformity has been proven.
Strength of Evidence — Not Recommended, Evidence (C) · confidence moderate · p. 172
Indications — required:
Concomitant instability or deformity has been proven
“There is no quality evidence of benefit to adding lumbar fusion to decompression.” — p. 170
Not recommended unless concomitant instability or deformity has been PROVEN. The guideline states there is no quality evidence of benefit to adding fusion to decompression, and that fusion's role is to treat instability if proven present. If instability is proven, request under the spondylolisthesis/instability checklist, where the guideline sets numeric criteria.