Right L5-S1 lumbar laminotomy with microdiscectomy (CPT 63030)
All other reasonable sources of pain and/or neurological deficit have been ruled out, including but not limited to significant pathology at other spinal level(s) on the advanced imaging radiology report that is/are not part of the surgical request resulting in incomplete surgical planning
CPB 0743, criterion 1
Member has signs or symptoms of neural compression (radiculopathy, neurogenic extremity claudication, myelopathy) associated with the levels being treated
CPB 0743, criterion 2
Advanced imaging studies (CT or MRI) indicate central/lateral recess or foraminal stenosis (graded as moderate, moderate to severe or severe; not mild or mild to moderate), or nerve root or spinal cord compression, at the level corresponding with the clinical findings
CPB 0743, criterion 3
Member's activities of daily living are limited by symptoms of neural compression
CPB 0743, criterion 5
Member has failed at least 6 weeks of conservative therapy
CPB 0743, criterion 4 + Footnote 1
Conservative measures were recent (within the past year)
CPB 0743, Footnote 1
Active in-person physical therapy (not home or virtual) for the entire required duration, confirmed by the actual PT notes or by documentation in the member claims history
CPB 0743, Footnote 1
Trial of medications (NSAIDs, acetaminophen, or tricyclic antidepressants)
CPB 0743, Footnote 1
Patient education provided
CPB 0743, Footnote 1