Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement at C4-C5 and C5-C6. In a prospective, randomized, controlled multicenter investigational device exemption clinical trial comparing cervical total disc replacement compared with anterior cervical discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease, researchers concluded that two level cervical total disc replacement (TDR) was superior to anterior cervical discectomy and fusion (ACDF), and that the differences in clinical effectiveness of TDR versus ACDF became more apparent as treatment increased from one to two levels. The authors further noted that both surgeries had lower rates of second surgery, higher adjacent level disc survivorship, and were effective in alleviating pain relative to baseline. In a study of the clinical and radiographic outcomes of 23 multilevel cervical myelopathy (MCM) patients treated with a hybrid technique combining cervical anterior corpectomy and fusion (ACF) with cervical artificial disc replacement, researchers reported that the results revealed that this hybrid technique is both technically feasible and effective for the treatment of MCM, however the authors noted that future comparative studies will be required to determine the potential benefits and pitfalls of this hybrid technique. In this case, the records noted diagnoses of cervical degenerative disc disease, cervical disc herniation, cervical radiculopathy, and cervical myelopathy. The records noted significant stenosis mainly at the C3-C4 and C5-C6 levels. On examination of the cervical spine, there was tenderness along the left splenius capitis and left levator scapulae, and a Spurlings test was positive on the left. There was diminished range of motion in all planes. Notes reported that magnetic resonance imaging (MRI) of the cervical spine showed multilevel pathology including at C3-C4, C4-C5, C5-C6, and C6-C7. The treatment plan included C3-C4 and C6-C7 anterior cervical discectomy and fusion with a C4-C5 and C5-C6 artificial disc replacement. While current medical literature supports two-level contiguous cervical artificial disc replacement and provides some support for hybrid artificial disc replacement and fusion surgery at three levels, given that the requested service is for four levels and as additional studies are needed to support hybrid artificial disc replacement and fusion, the requested services are not medically indicated. Therefore, artificial disc replacement at C4-C5 and C5-C6 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.