Surgery for lumbar radiculopathy/sciatica

Coverage Decision: Covered with conditions

Conditions of Coverage

Open discectomy or microdiscectomy with or without endoscopy (lumbar laminectomy, laminotomy, discectomy, foraminotomy) are covered with the following conditions:

  • For adult patients with lumbar radiculopathy with subjective and objective neurologic findings that are corroborated with an advanced imaging test (i.e., Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) or myelogram), AND
  • There is a failure to improve with a minimum of six weeks of non-surgical care, unless progressive motor weakness is present
Non-covered indicators:

Minimally invasive procedures that do not include laminectomy, laminotomy, or foraminotomy including but not limited to energy ablation techniques, Automated Percutaneous Lumbar Discectomy (APLD), percutaneous laser, nucleoplasty, etc. are not covered.

Background Information

The State Health Technology Clinical Committee (HTCC) reviewed surgery for lumbar radiculopathy/sciatica in May 2018 and finalized the determination on July 13, 2018.  Complete information on this HTCC determination is available at: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850.  Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).

Implementation of the Coverage Decision

All requests for surgery for lumbar radiculopathy/sciatica require prior authorization.  The service may be covered only for care of a condition accepted on or related to the claim.

For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).

 

For State Fund Claims

Please contact Utilization Review Vendor (Comagine): http://www.lni.wa.gov/ClaimsIns/Providers/AuthRef/UtilReview/default.asp

For Self-Insured Claims
Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

For more information:
Contact information.

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