The Department has issued new stricter guidelines regarding when a proposed lumbar fusion is a medically necessity and clinically appropriate. These guidelines, effective March 7, 2016, deny lumbar fusion surgery coverage for patients with uncomplicated degenerative disc disease (“DDD”).
An uncomplicated DDD is one where claimant has lower back pain without any evidence of: (1) radiculopathy, (2) functional neurologic deficits, (3) spondylolisthesis (greater than grade 1), isthmic spondylolysis, (4) primary neurogenic claudication associated with stenosis, (5) fracture, tumor, infection, inflammatory disease, or (6) degenerative disease associated with significant deformity. The current guidelines allowed a coverage for a lumbar fusion for a claimant who had no evidence of the above 6 conditions, as long as they completed three months of conservative therapy and structured, intensive, multidisciplinary program (“SIMP”) treatment.
These new stricter guidelines are a based on the Health Technology Clinical Committee determination. If you would like a copy of the new guidelines please click here. Or feel free to email me for a copy or any questions you have about the Department’s treatment coverage in Washington at .