Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vertebral Compression Fracture
Treatment: Spinal surgery/kyphoplasty, 01 Unit
The insurer denied coverage for spinal surgery/kyphoplasty, 01 Unit
The denial is overturned.

This case involves an adult patient with a history of back pain. The patient presented for an evaluation related to pain in the low back with radiating symptoms into the lower extremities. The patient reported a snapping sensation in the back while pushing something approximately 2 months prior. The patient had pain that was progressively worsening. Prior treatment included physical therapy and nonsteroidal anti-inflammatory medications. The patient reported stiffness and paravertebral muscle spasms. The patient reported deficits in activities of daily living. The patient rated the pain 8 out of 10. The physical exam findings of the patient noted spasms and tenderness to the paravertebrals of the cervical spine and trapezius.  There was positive Spurling maneuver bilaterally. The patient had decreased deep tendon reflexes in the biceps bilaterally and the brachial radialis on the left. The exam findings of the lumbar spine noted tenderness to palpation at the Lumbar (L)3 region. The patient had decreased range of motion of the lumbar spine. There were spasms and tenderness to the paravertebrals of the lumbar spine. There was negative straight leg raise testing. The patient had 5 out of 5 strength in the bilateral lower extremities. The patient had decreased deep tendon reflexes on the right knee and on the left in the ankle. Radiographs of the lumbar spine noted osteopenia with new L3 compression deformity with approximately 15% loss of vertebral body height. There was mild multilevel degenerative disc disease. Magnetic resonance imaging noted acute mildly L3 vertebral body compression fracture without retropulsion. There was mild multilevel degenerative change. The provider discussed surgical intervention. The patient wanted to try injection prior to consideration for surgery. However, the provider also indicated that they were scheduling L3 kyphoplasty.

Reconsideration for the patient's L3 kyphoplasty was requested. The patient complained of low back pain that radiated down both the lower extremities. The patient reported that 2 months prior, they felt a snap in the back while pushing a heavy object. The pain had progressively worsened since that time. The patient participated in conservative treatment including physical therapy and nonsteroidal anti-inflammatory medications without improvement. Magnetic resonance imaging showed acute mildly L3 vertebral body compression fracture without retropulsion. Given failure of conservative treatment and ongoing symptoms, reconsideration for L3 kyphoplasty was requested.

Per the cited references, kyphoplasty is indicated for osteoporotic vertebral compression fractures confirmed by advanced imaging following failure of nonsurgical management. The documentation should identify pain causing loss of mobility or inability to perform baseline levels of daily activities and no unstable vertebral fractures. In this case, the patient had subjective and objective clinical findings of vertebral fracture at L3, confirmed with imaging, and had failed nonoperative treatment. The provider confirmed a plan to proceed with surgery.  Based on the provided findings, proceeding with the surgical intervention is medically necessary. As such, the denial of coverage for spinal surgery/kyphoplasty, 01 unit requested is overturned.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for spinal surgery/kyphoplasty, 01 Unit is substantiated.