Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder
Surgical Services

This is a patient  with a long history of spinal disorders and surgeries. He underwent and lumbar (L) 1 to L5 fusion a number of years ago with a recent extension of the decompression and fusion up to thoracic (T) 8. He also has a long history of neck pain and arm symptoms and underwent an anterior cervical discectomy and fusion (ACDF) at C5-6 and C6-7. He presented with a recurrence of neck pain and has been seen a number of times with neck pain and complaints of predominantly left arm parethesias. He complained of the onset of bilateral shoulder pain and new right arm numbness that started in summer 2018. A cervical epidural steroid injection (ESI) did not provide relief. A cervical magnetic resonance imaging (MRI) scan reported some ASD (adjacent segment disease) at C3-4 and C4-5 with bilateral NFS (neural foraminal stenosis) C3-4 and right (R) NFS C4-5. Subsequently, he underwent the thoracolumbar procedure noted above then returned to the clinic wanting to do something about his chronic neck pain. The exam at that visit showed no neurological deficits other than old sensory loss in the left C7 dermatome.
Cervical flexion and extension x-rays (XRs) were done and showed no abnormal motion and intact fusion C5 to C7. An MRI scan was also obtained and initially read as no spinal cord signal changes, some adjacent degenerative disease at C3-4 and C4-5 with mild to moderate canal stenosis and moderate bilateral NFS at both levels. An addendum was added at the provider's request that now upgrades the degree of canal stenosis at both C3-4 and C4-C5 to moderate but still without any report of significant cord compression or signal change.
The provider has recommended ACDF C3-4 and C4-5 to prevent neurological decline, according to the letter submitted for the appeal of the health plan's denial for this procedure. The health plan denied the procedure as not being medically necessary for this patient at this time due to lack of reasonable conservative therapy in the recent past. At issue is the medical necessity of the requested surgery.
The health plan's determination is upheld. The requested surgical treatment is not medically necessary for this patient at this time.
The patient has a long history of chronic neck pain and various radicular symptoms over the years which seem to change and resolve. The last documentation of significant radicular symptoms was the onset of bilateral shoulder and arm pain and right finger numbness described in an office visit but not mentioned in the last visit where the surgery was being recommended. Only neck pain was mentioned at that visit. And while there has been some progression of ASD (adjacent segment disease) by MRI, there still is no description of significant cord compression or new signal change within the spinal cord or evidence on clinical exam of cervical myelopathy that would make the requested procedure urgent/emergent. Therefore, there is no reason why the patient could not undergo a course of conservative therapy for his chronic neck pain at this time. Apparently, the cervical ESI  was not helpful but there are no records of other interventions for neck pain such as facet medial branch blocks/radiofrequency ablation or comprehensive physical therapy/therapist directed home exercise program.
Cervical fusions for neck pain alone are controversial (Riew et al), as is cervical decompression to "prevent" neurological injury without imaging that shows severe spinal cord compression . As to the latter point, several recent reviews regarding best practices in the management of cervical myelopathy have led to the recommendation to not offer prophylactic surgery for nonmyelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy, and also noted there was very weak evidence that surgery is necessary for patients with mild and stable DCM (degenerative cervical myelopathy). (Fehlings et al and Wilson et al). These same reviews of the evidence found moderate quality evidence to strongly support the recommendation for surgery in patients with moderate to severe DCM. This patient has no clinical findings of DCM on exam and therefore currently would fall into the nonmyelopathic category.
In terms of the ASD, it is certainly recognized that there an up to 25-50% incidence of that occurring after prior ACDF. (Alhashash et al). Clinical outcomes following ACDF for ASD can lead to improved symptoms of myelopathy, radiculopa thy and even neck pain as reported by O'Neill et al and Li et al. However, these were retrospective reviews without a control non-surgical group undergoing traditional conservative measures. In addition, the proposed procedure would give this patient an ultimate 4 level cervical fusion, with known clinical outcomes regarding cervical pain to be worse in 4 level fusion patients. (De la Garza et al).