Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain.
Treatment: Lumbar surgery (63185 x 1, 22830 x 1, 63042 x 1).
The insurer denied coverage for lumbar surgery (63185 x 1, 22830 x 1, 63042 x 1).
The denial is upheld.

This case involves an adult and is under review for surgical intervention. Clinical notes reported the patient was status post posterior fossa decompression with no improvement in preoperative symptoms. Magnetic Resonance Imaging (MRI) of the brain completed revealed normal findings with absence of prior Chiari malformation. The clinical note reported the patient had complaints of headaches, bilateral upper extremity neuropathy, and tongue/lower face pain. The patient had styloid hypertrophy with positive results from glossopharyngeal block. There was bilateral impingement of the anterior jugular veins by the tubercles of C1 (cervical). It was noted that conservative management had failed. The patient was recommended for a C-spine MRI and consultations as the patient was a candidate for surgical intervention. Neurosurgical consultation reported the patient was being followed for Ehlers-Danlos syndrome headaches and possible cranial instability as well as possible Eagle syndrome. The patient continued to have severe pain and headaches as well as episodes of weakness. The treatment plan was for MRI and medication management. Psychological evaluation noted the patient had no contraindications for surgical intervention. An MRI of the cervical spine was completed and noted normal Cerebral Spinal Fluid (CSF) flow and slightly low-lying cerebral tonsils likely within normal limits.  The determination letter reported the requested procedure was denied. The letter reported the patient had previously undergone invasive cervical traction and other operative diagnostic testing. The patient had been recommended for posterior fossa decompression. The provider noted the patient had failed all other means of treatment and was severely disabled due to ongoing symptoms. An appeal letter noted the patient had a history of Arnold-Chiari syndrome, spinal instabilities, and Ehlers-Danlos syndrome. The patient was experiencing worsening instability, severe headaches, neck pain, visual disturbance, brain fog, and generalized weakness.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The lumbar surgery (63185 x 1, 22830 x 1, 63042 x 1) is not considered medically necessary for this patient. In this case, the patient has a history of Arnold-Chiari syndrome, spinal instabilities, and Ehlers-Danlos syndrome. The patient was experiencing worsening instability, severe headaches, neck pain, visual disturbance, brain fog, and generalized weakness. The patient underwent a posterior fossa decompression. Recent imaging did not reveal any significant pathology to warrant additional surgery. As such, the request for lumbar surgery (63185 x 1, 22830 x 1, 63042 x 1) is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for lumbar surgery (63185 x 1, 22830 x 1, 63042 x 1) is not substantiated.