Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CPT codes: 22633- Posterior lumbar interbody fusion, lumbar five to sacrum one (L5-S1), 63047- laminectomy, lumbar five to sacrum one (L5-S1), 22840- posterior instrumentation (Depuy Expedium Verse screws), 22853- synthetic cage/spacer (K2M Cascadia TL Implant System Cage), 20930- allograft (Medtronic Progenix DBM), 20936- autograft.

Treatment: Inpatient Stay

The insurer denied the inpatient stay. The denial was reversed.   

This is a female patient with a history of cervical radiculopathy, chronic back pain, and disc herniation. The patient consulted a neurosurgeon. A magnetic resonance imaging (MRI) of the lumbar spine was performed that revealed loss of disc signal lumbar five (L5)-sacral one (S1); broad bulge with central herniation contacting but not displacing the S1 nerve roots.  The patient started physical therapy; it was reported that it worsened her symptoms. On re-evaluation the patient reported having agonizing, unremitting lower back pain, which interferes with activities of daily living (ADL's). A lumbar computed tomography (CT) scan showed a large left posterolateral radial tear of the disc at L5-S. There was a small right-sided radial tear at L4-5. The plan was for an L5-S1 posterior lumbar interbody fusion.

 According to the InterQual Criteria for Fusion, Lumbar Spine, the patient met the following criteria for lumbar spine fusion: the patient was noted to have degenerative disc disease by MRI; the patient had back pain that interfered with activities of daily living; the patient had no neurological deficit; the patient had no psychiatric disorder; the patient was not a smoker; the patient has trialed NSAIDs/Tylenol, physical therapy/home exercise and activity modification for at least 6 months.

The International Society for the Advancement of Spine Surgery (ISASS) states that a lumbar fusion is indicated for: Degenerative Disk Disease (DDD), and that a lumbar spinal fusion surgery is medically indicated - at a maximum of two levels - when all of the following conditions are met: the patient presents with clinically important pain and disability consistent with diskogenic pain; MRI (or other imaging) demonstrates morphological disk degeneration; The patient has not shown sufficient improvement from a minimum of 6 consecutive months of structured conservative medical management (including at least pain medication, activity modification, and daily exercise), with adequate patient compliance; the patient has then subsequently not shown sufficient improvement from a program of intensive multidisciplinary rehabilitation, (with a minimum volume of 80 hours of on-site treatment during a 2-4 week period, including a cognitive- behavioral component), if such a program is locally available and covered by the patient's insurance; the patient has been appropriately screened for possible mental illness and/or substance abuse issues, and if present has undergone professional treatment for these issues; the patient is not currently involved in an ongoing litigation case related to his or her back. (This does not refer to "worker's compensation".); the patient is age 25-65; the patient is not pregnant; either provocative discography (with concordant pain and negative adjacent levels) or magnetic resonance spectroscopy (MRS) has provided corroborating evidence that the patient's pain is likely due to the disk degeneration observed on imaging, and the two are not merely an unrelated coincidence.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for spinal surgery with the associated inpatient stay is reversed.  The medical necessity is substantiated.