Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back and leg pain
Treatment: Back surgery 
The insurer denied Back Surgery.
The determination is upheld. 


The patient has a history of low back and left leg pain.The patient underwent a left lumbar (L) 3-4 discectomy for extraforaminal disc herniation but has had persistent pain. She has had physical therapy, injections and medications without relief. She is a non-smoker. The neurologic exam shows no motor weakness. The lumbar magnetic resonance imaging (MRI) shows a persistent left foraminal disc herniation at L3-4. The provider has recommended an L3-4 fusion. At issue is the medical necessity of the requested back surgery.

No. The requested procedure is not medically necessary. Based on AIM guidelines, the procedure is not medically necessary. The patient had a procedure less than 3 months ago, the patient did not have any relief of symptoms, and there is no evidence of instability.

Lumbar fusion guidelines:
-Disc herniation
  Recurrent, same level, disc herniation when all of the following are 
  demonstrated:
1)at least three months have elapsed since the prior procedure-NOT MET,
2) the patient experienced significant relief of symptoms following the procedure-NOT MET,
3)recurrent symptoms or functional impairment have not responded to at least 12 weeks of conservative management-NOT MET,
4)neural compression correlating with the clinical presentation and instability is demonstrated on imaging studies-NOT MET.

The literature does not completely support lumbar fusion for recurrent disc herniation without evidence of instability. Dower et al cite, "This systematic review was performed to evaluate the various operative management strategies for recurrent lumbar disc herniation (RLDH), including the efficacy of instrumented spinal fusion (ISF) at repeat discectomy, and whether the operative approach for repeat discectomy, minimally invasive (MID) or conventional open discectomy (CD), affected the outcomes. RLDH is one of the most common complications of lumbar discectomies.
There is no evidence to recommend the routine addition of instrumented spinal fusion in the management of RLDH. The data suggest that MID has lower complication rates than CD in the setting of RLDH, yet unequivocal evidence is lacking".
Tanavalee et al cite, "Recurrent lumbar disc herniation is a common negative sequela of primary discectomy. Repeat discectomy versus spinal fusion is constantly debated, and successful outcomes from both treatments remain unclear. The improvement rate was not different between the two groups. In conclusion, no difference in re-operation rates between the two surgical treatments was found based on the results of our study. Both treatment techniques have equal improvement rates and complications". Kerezoudis et al cite, "Available evidence shows that in treating one-time recurrent disc herniations, repeat discectomy and fusion are associated with comparable reoperation rates, incidence of dural tears, functional outcomes as well as satisfaction with surgical treatment at last follow-up. Future longitudinal, randomized controlled trials should be completed to validate any associations found in this study".