Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Orthopedic/Musculoskeletal
Diagnosis: Neck and Arm Pain
Treatment: Surgical Services (Spinal)
The health plan denied the request for surgical services. 
The health plan's determination is upheld.

The patient is a male who was seen by the surgeon for a long history of neck pain and progressively worsening left arm pain. His physical examination revealed normal motor and sensory functions, a normal gait and symmetrical deep tendon reflexes. He apparently had undergone physical therapy treatments and injections without relief. In the office visit note the magnetic resonance imaging (MRI) of his cervical spine is described as showing severe degenerative disc disease with significant left greater than right neural foraminal stenosis at C56 and C67. The only imaging report that is available for review is from radiographs of the cervical spine which reported mild degenerative changes only at C56. The surgeon recommended a 2-level ACDF (anterior cervical discectomy and fusion) C56 and C67, and apparently the request was received by the health plan. This was denied as no MRI scan report had been submitted, even after a written fax was sent to the surgeon's office requesting this information. The question for this review is regarding the health plan's decision to deny the request for the ACDF procedure.

The health plan's determination is upheld, in whole.

No, the requested treatment of a 2-level ACDF cannot be considered medically necessary for this patient without an MRI scan that shows significant neural compression that correlates with his clinical symptoms and without documentation that the patient is either a non-smoker or a former smoker.
Not only was the MRI scan report not submitted for review, there also is no information in the documents submitted for review regarding the particulars of the attempts at conservative treatment, including types and dates of injection therapies and dates/duration of physical therapy. Equally important is the lack of smoking/tobacco use status of this patient.
Firstly, significant neural compression that correlates with the patient's clinical symptoms and physical examination is critical in making the decision to offer surgery, as well as the request for surgery being approved by the health plan. Without the report of the MRI it is impossible to consider approving a 2-level ACDF for this patient.
In addition, it is well recognized by the spinal surgery community that current tobacco/nicotine use has a negative impact on fusion rates, leading to higher surgery failures and the potential for revision surgery. Smoking cessation is widely recommended preoperatively unless there is an urgent neurological reason to proceed. Lastly, adequate attempts at conservative treatment within a reasonable time frame is generally recommended as well as these conservative efforts can prove effective and avoid surgical intervention. This patient has a long history of pain - one would need to know that adequate conservative interventions had occurred within the last 6 - 12 months before considering surgery medically necessary in the face of a patient with pain but no neurological deficit on examination.