Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Back Pain
Treatment: Surgical Services-Transpedicular approach
The health plan denied the Transpedicular approach as not medically necessary. 
The reviewer has overturned in whole the health plan determination.

The patient was seen in clinic with continued low back pain and sharp shooting pain radiating into the left buttocks, left hip, and left groin, and left posterior calf. The patient reports paresthesias to the left anterior thigh and foot and has bilateral leg discomfort and anterior thigh paresthesias and frequent muscle spasms. The patient states her anus and buttocks are numb and has had a full course of physical therapy and pain management injections which were ineffective. The patient has lost 10 pounds which has not helped  symptoms and has recently quit smoking. A magnetic resonance imaging (MRI) scan  shows Lumbar5-Sacral1(L5-S1) disc bulge causing moderate to severe spinal stenosis. A computed tomography scan of the lumbar spine showed severe degenerative disease at L5-S1. The patient is currently taking gabapentin 3 times a day. At this point based on the symptoms and failure of conservative management the patient has elected to proceed with surgical intervention. Preoperative and postoperative diagnoses were status post lumbar laminectomy with bilateral right greater than left radiculopathy, degenerative disc disease requiring total facetectomy for foraminal narrowing. The procedure performed was a posterior spinal fusion with instrumentation L5-S1, revision L5-S1 hemilaminectomy, right L5-S1 total facetectomy/transpedicular lumbar decompression, transforaminal lumbar interbody fusion, application of intervertebral cage L5-S1. Application of local bone graft and allograft to posterior arthrodesis site, and application of structural bone graft to the anterior arthrodesis site. 
The service of Transpedicular approach was medically necessary for this patient.
The current procedural terminology Code 63056 is defined as a transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment. As per the operative note, the surgeon did conduct a complete facetectomy and transpedicular approach with subsequent decompression followed by reconstitution of the transpedicular defect with bone grafting.
The surgeon states that a complete facetectomy was performed and a transpedicular approach was needed. Based on the dictated operative note, the surgeon states, "Next, attention was then turned to a right sided transpedicular lumbar decompression. A total facetectomy/transpedicular lumbar decompression was performed. There is severe bony stenosis on the L5 nerve root necessitating a total facetectomy." This procedure included decompression of the L5 nerve root and removal of hypertrophic osteophytes off of the superior articular process of S1. Discectomy was performed at L5-S1 on the right and subsequent L5-S1 transforaminal lumbar interbody fusion. Further in the operative note the surgeon states that fibrillar was applied to the right L5-S1 transpedicular lumbar decompression defect. Based on the operative note provided for review and the current procedural terminology (CPT) code definition for transpedicular approach, the request would be fulfilled and certified.