Medical Necessity Determination for Annular Closure Device with L4-S1 Laminectomy
Primary Determination
The L4-S1 hemilaminectomy, medial facetectomy, and microdiscectomy are medically necessary and meet all established criteria, but the annular closure device (CPT codes C9757 and 22859) is NOT medically necessary as it is considered unproven and lacks sufficient evidence for effectiveness. 1
Laminectomy/Discectomy: MEDICALLY NECESSARY
Criteria Met for Standard Decompression
The patient meets all five required criteria for lumbar laminectomy as outlined in the clinical policy bulletin:
Neural compression confirmed: Patient has documented right L5 radiculopathy with severe central canal and right lateral recess stenosis at L4-5, plus moderate stenosis at L5-S1 with nerve root encroachment 2, 3
Advanced imaging demonstrates appropriate severity: MRI shows severe spinal stenosis at L4-5 and moderate spinal stenosis at L5-S1 (not mild or mild-to-moderate), with extruded disc fragments and caudal migration 2
Conservative therapy completed: Patient completed 10 sessions of physical therapy with temporary improvement, plus trial of medications, heat, and ice over appropriate timeframe 2, 4
Activities of daily living limited: Symptoms worsen with standing/walking, causing bilateral foot numbness and limiting functional capacity 2
Other pathology ruled out: Clinical examination and imaging correlate appropriately with no confounding pathology at other levels 2
Evidence Supporting Bilateral Partial Laminectomy Approach
Bilateral partial laminectomy for lumbar stenosis and disc herniation demonstrates 88-91% overall improvement at long-term follow-up (mean 3.5 years), with better preservation of spinal architecture compared to total laminectomy 2
This less radical approach reduces subsequent fusion requirements while maintaining excellent outcomes, with only 2 of 152 patients requiring subsequent fusion 2
Multilevel laminotomies for focal lateral recess stenosis show 90% excellent outcomes with total symptom relief and return to normal activities, with no significant morbidity 3
Annular Closure Device: NOT MEDICALLY NECESSARY
Policy Exclusion
The clinical policy bulletin explicitly states that annular repair devices (including codes C9757 and 22859) are "considered unproven because of insufficient evidence of their effectiveness." This is a definitive exclusion that supersedes clinical judgment. 1
Rationale for Exclusion
Lack of high-quality evidence: No guideline-level evidence supports routine use of annular closure devices for lumbar disc herniation with annular defects 1
Standard discectomy sufficient: The presence of an annular defect does not change the indication for or expected success of standard microdiscectomy, which has well-established 69-87% success rates without annular repair 2, 5, 4
No fusion indicated: Simple laminectomy and discectomy for herniated lumbar disc without instability or spondylolisthesis does not require fusion or additional stabilization devices, with fusion actually producing less excellent results (11% vs 29% excellent outcomes) and longer return-to-work times 5
Clinical Context
The patient has no documented instability, spondylolisthesis, or other structural pathology that would justify additional hardware beyond standard decompression 5, 4
Recurrent disc herniation, if it occurs, can be adequately treated with repeat laminectomy and discectomy alone (69% good results) without requiring fusion or annular repair devices 4
Recommended Surgical Plan
Approved Procedures
Right-sided L4-5 hemilaminectomy, medial facetectomy, foraminotomy, and microdiscectomy for severe stenosis with extruded disc and right L5 radiculopathy 2, 3
Right-sided L5-S1 hemilaminectomy, medial facetectomy, foraminotomy, and microdiscectomy for moderate stenosis with disc extrusion and right S1 nerve root encroachment 2, 3
Procedures NOT Approved
Annular closure device insertion (C9757, 22859): Explicitly excluded as unproven technology 1
Fusion procedures: Not indicated in absence of instability or spondylolisthesis 5
Critical Pitfalls to Avoid
Do not conflate annular defect with need for repair: Annular defects are common findings after disc herniation and do not independently justify device placement when policy explicitly excludes such devices as unproven 1
Do not add fusion to simple discectomy cases: This increases morbidity, delays return to work, and produces inferior excellent-outcome rates without improving overall success 5
Bilateral vs unilateral approach: While imaging shows bilateral pathology, the clinical presentation is predominantly right-sided radiculopathy; surgical extent should match symptomatic distribution to avoid unnecessary bilateral exposure 2, 3