Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Lower Back Pain

Treatment: the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L [lumbar] 5-S [sacral] 1) and one inpatient bed day

The insurer denied coverage for the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day

The denial is overturned

This case involves an adult male with request for single level lumbar arthrodesis procedure. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc desiccation and mild to moderate disc height loss at L5-S1 with associated minimal Modic type I endplate degenerative changes. There was also a small disc bulge with a superimposed central disc extrusion with slight inferior migration causing mild spinal canal stenosis and contact of the bilateral traversing S1 nerve roots. The patient also had mild bilateral facet arthropathy, moderate left neuroforaminal stenosis, and mild to moderate right neuroforaminal stenosis. Radiographs of the lumbar spine revealed no change in lumbar spine alignment on flexion or extension views. There was disc base narrowing with osteophytosis at L5-S1. The patient was seen for initial visit with complaints of low back pain for years which had increased in the past 6 months. The patient reported low back pain radiating into the bilateral gluteals. Past treatment included physical therapy program, multiple lumbar epidural steroid injections, and radiofrequency ablation with minimal relief of pain. Medication regimen included Tylenol, ibuprofen, and tetrahydrocannabinol (THC). The patient reported another spine surgeon told him he was a candidate for spinal fusion. Physical examination revealed 5/5 motor strength in lower extremities, pain with range of motion of the lumbar spine, intact sensation, and symmetric deep tendon reflexes. Prior diagnostics were reviewed. The patient was recommended for surgical intervention at L5-S1 and preferred artificial disc replacement over fusion. 

This case involves an adult male with request for single level lumbar arthrodesis procedure. This procedure has been FDA (Food and Drug Administration) approved and has been shown to be safe and effective per literature. Total disc arthroplasty has been shown to be safe and effective, comparable to lumbar fusion, with advantages to include maintenance of segmental motion and the restoration of the disc height. This procedure is not considered experimental or investigational given the available literature and FDA approval. 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. Total disc arthroplasty described by code 22857 at L5-S1, does have final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the total disc arthroplasty at L5-S1. The total disc arthroplasty is the best available treatment for this patient at this time. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The adverse risks are not increased over standard treatment/services

The carrier's denial of the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day should be overturned.