Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain
Treatment: Total disc arthroplasty [CPT 22857, 22860]
The insurer denied: Total disc arthroplasty [CPT 22857, 22860]
The denial is upheld.

The patient is an adult female. The patient has complaints of lower back pain and has been recommended for a total disc arthroplasty. The patient sustained a work-related back injury in the lumbar spine several years ago. The patient has had episodes of acute and chronic flare. The patient has been diagnosed with osteoporosis. She has been under the care of an endocrinologist. The patient has had previous treatment with rest, multiple medications, topical medications, a back brace, and physical therapy for the past year. The patient has also had treatment with chiropractic care. The patient had spinal injections previously. MRI (magnetic resonance imaging) of the patient's lumbar spine from 2 months ago showed disc desiccation with an annular fissure and mild disc bulge at L5-S1 (lumbar five to sacral one). There is disc desiccation with mild loss of disc height and subtle annular fissure and mild disc bulge at L4-5 (lumbar four to five). There is disc desiccation with mild loss of disc height and annular bulge with small central extrusion at L1-2 (lumbar one to two). There is no significant nerve impingement at L4-5 (lumbar four to five) or L5-S1 (lumbar five to sacral one). There was mild lower lumbar facet arthropathy. 

Flexion-extension radiographs showed no evidence of segmental instability. There was a very mild convex left upper lumbar curvature. There is mild to moderate facet arthropathy. This x-ray was taken 3 months ago. The patient had a DEXA (dual-energy x-ray absorption) scan 7 months ago showing osteopenia in the lumbar spine, bilateral hips and left wrist. The patient was evaluated 6 months ago for preoperative intervention. The patient was recommended for a hybrid procedure with an anterior lumbar interbody fusion of L5-S1 (lumbar five to sacral one) and a disc replacement at L4-5 (lumbar four to five). The DEXA (dual-energy x-ray absorption) scan showed improved osteopenia. The doctor indicated that the values are less than optimal for 2 level disc replacement. The patient had a discogram evaluated 2 years ago with 10/10 concordant pain at L4-5 (lumbar four to five) and 9/10 pain at L5-S1 (lumbar five to sacral one). There was an abnormal pattern and the leak at both levels. There was no control level provided. This is a review for the 2-level lumbar disc arthroplasty.

The Total disc arthroplasty [CPT 22857, 22860] is not medically necessary.

The patient has been recommended for a 2-level disc arthroplasty for discogenic pain. The patient has evidence of osteopenia and the doctor indicated that the patient was at risk for subsidence and the DEXA (dual-energy x-ray absorption) scan did not show optimal findings to support the need for a 2-level disc arthroplasty. Thus, the treatment would not be medically necessary based upon the patient's bone density. Furthermore, there is concern for lack of significant pathology at the L4-5 (lumbar four to five) and L5-S1 (lumbar five to sacral one) levels. Given the MRI (magnetic resonance imaging) findings, a clear pain generator has not been established. The patient had diskography, but this has not been shown to be an accurate method to determine the pain generator in the lumbar spine. The patient has multilevel disease at L4-5 (lumbar four to five), and L5-S1 (lumbar five to sacral one) as well as discogenic findings at L1-2 (lumbar one to two). Without a clear pain generator, and without evidence of nerve compression or corresponding radiculopathy, the need for the disc arthroplasty at 2 levels cannot be supported as medically necessary.