Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Back pain
Treatment: Surgical Services-Back Surgery
The health plan denied the back surgery as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

Patient has a complex spinal history. She underwent posterior Harrington rod placement for adolescent idiopathic scoliosis (AIS) as a teenager. Her rods were removed, and she had a right (R) sided thoracoplasty and a lumbar (L) 5/sacral (S) 1 instrumented fusion. The patient did well for approximately 20 years but over the past 3 years has had increasing deformity, low back pain, and right greater than left (R>L) leg pain. X-rays demonstrate 35 degrees of lumbar scoliosis with lateral listhesis of L2/3 and right sided truncal shift. Her deformity has been progressive over the past 5 years based on prior x-rays. A computed tomography scan shows the prior L5/S1 fusion and significant facet arthropathy diffusely. A magnetic resonance imaging scan shows diffuse degenerative changes with mild to moderate stenosis from L2-5. The electromyography testing was within normal limits. Treatment to date has included physical therapy (PT), medication, epidural steroid injection (ESIs), trigger point injections, and facet injections. Patient was recommended L3-5 decompression with extension of her fusion to L1. 

Yes, medical necessity is met. This is a patient with spinal deformity/scoliosis. She has had 2 prior major spinal surgeries for this, which were both successful. She has unfortunately had continued progression of her deformity and resultant back and bilateral lower extremity (BLE) pain. Her imaging substantiates this. She has tried exhaustive conservative treatment to include PT, medication, ESIs, trigger point injections, and facet injections. Patient has lumbar scoliosis with radicular pain that results in significant functional impairment in a patient who has failed at least 3 months of conservative management, and has documented progression of deformity with persistent axial pain and functional impairment unresponsive to at least 3 months of conservative management. The patient's work-up, conservative management, and proposed treatment meet the standard of care. 

Scoliosis surgery for coronal imbalance and/or lateral listhesis with resultant back pain is a medically indicated surgery. Standard of care would be for surgical management in the event that non-surgical management fails. The included guidelines are consistent with the standard of care. Patient meets the included guidelines as well as the standard of care.

Per Tribus: "In a patient with lateral listhesis > 5 millimeter (mm), anterolisthesis, or residual disk space height with degenerative scoliosis, posterior fusion with instrumentation is reasonable... In the rare cases in which severe coronal or sagittal imbalance occurs, an extreme functional deficit frequently results. These patients often complain of mechanical back pain and may or may not have symptoms of neurogenic claudication. The deformity is usually one of sagittal imbalance with a lumbar flat back, but it also may include elements of coronal imbalance. Decompression alone in these patients has a very high rate of failure. The surgical plan should assure spinal balance and, in most cases, will require fusion to the sacrum."