Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided.  Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness. Lower extremity neurologic examination was within normal limits. Pelvic rock test was diminienrolleed on the right. X-rays showed mild scoliosis to the right and centered at L3. Moderate disc space narrowing at L3-4 and L4-5, and a grade 2 spondylolisthesis at L4 on L5. Flexion and extension x-rays demonstrated a slip of L4 on L5 that measured 6 mm. In flexion, the slip measured approximately 14.3 mm. There was a possible crack of the pars. The diagnosis was unstable spondylolisthesis at L4 on L5 with degenerative disc disease at L3-4 and L4-5. A magnetic resonance imaging (MRI) of the lumbar spine documented a 5 mm degenerative anterior spondylolisthesis of L4 with respect to L5. There was a 6 mm broad-based L4-5 central extrusion with 1 cm cephalad extension and severe facet and ligamentum flavum hypertrophy, which severely narrowed the canal redundant disc extending slightly cephalad into the neural foramen with mild to moderate left and mild right neuroforaminal narrowing. There was no definite pars defect identified and no bone marrow edema. At L3-4, there was a 2 mm anterolisthesis of L3 with respect to L4, a 4-5 mm diffuse annular bulge, and moderate facet and ligamentum flavum hypertrophy moderately narrowing the canal and neural foramen bilaterally, right greater than left. At L2-3, there was a 2 mm anterolisthesis of L2 with respect to L3, a 3 mm diffuse annular bulge, and slight facet hypertrophy mildly narrowing the canal. The neural foramen were patent. Patient was treated with physical therapy and epidural steroid injections. An updated lumbar spine MRI was performed with clinical history documented as spondylolisthesis with bilateral hip radicular pain. The impression listed the L4-5 space was similar to the previous exam with 5 mm anterolisthesis on the basis of degenerative change to the facet joints with a right paracentral and lateral subligamentous disc extrusion extending superior to the disc level 7 mm. This along with ligamentum flavum hypertrophy and medial facet joints contributed to severe central canal stenosis and right greater than left lateral recess stenosis. The degree of central canal compromise was progressive since the previous study. There was Modic type 1 signal alteration seen at the opposing left lateral endplates of L4-5 and redundant disc laterally contributing to moderate left greater than right foraminal stenosis. There was addition Modic 1 signal alteration of the left pars which was attenuated without a definite lysis. At L3-4, there was a 4 mm diffuse annular bulge, and medial facet joint hypertrophy with ligamentum flavum hypertrophy creating a dorsolateral compromise of the thecal sac. There was moderate right L4 lateral recess stenosis, and significant Modic 1 signal alteration of the central and right lateral endplates, not present previously. There was a more focal right foraminal disc protrusion along with diffuse annular bulge and facet joint hypertrophy contributing to moderate right L3 foraminal stenosis, somewhat progressive in comparison to the previous study. At the L2-3 disc space, there was minimal left-sided anterolisthesis and a 2-3 mm diffuse annular bulge with minimal left subarticular and proximal foraminal stenosis, which was stable. There was levoscoliosis present. Patient underwent a dorsal fusion of the L4 and L5 segments with pedicle screw system, and dorsal dynamic pedicle instrumentation of the L2-L4 segments with a pedicle based dynamic stabilization system. Patient underwent ventral nucleotomy, decompression, mobilization segments at L2-3, L3-4, and L4-5, implantation of a cage endoskeleton (anterior lumbar interbody fusion) at L4-5, and implantation of a ProDisc-L total disc prosthesis at L2-L4 with bone cement in the vertebral bodies of L2-L4 . The diagnosis was documented as degenerative disc disease at L3-4 and L4-5, degenerative pseudolisthesis at L4-5, osteopenia, and degenerative scoliosis L2-L5.  the patient had presented her medical history for evaluation of options of a non-fusion or hybrid (fusion/non-fusion) spinal procedure. There is documented severe chronic back pain, non-responsive to intensive non-surgical treatment. The patients records were reviewed and demonstrated severe multilevel degenerative of the lumbar spine affecting both the intervertebral disc spaced and alignment. The patient has requested reimbursement for surgical and related services provided. At issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The surgical and related services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. Patient presented with degenerative disc disease at L3-4 and L4-5, degenerative spondylolisthesis at L4-5, osteopenia, and degenerative scoliosis L2-L5. Enrollee underwent anterior lumbar interbody fusion at L4-5 and ProDisc-L artificial disc replacement at L2-L4 using a dynamic stabilization system at L2-L5. Enrollee reported progressive pain and functional limitations. However, the surgery at issue did not warrant emergency surgery. The patient did not receive emergency medical services at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services at issue.