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

Nature of Statutory Criteria/Case Summary: The patient is a 46-year-old female who was diagnosed with degenerative vertical segmental instability at C4-5 and C7-T1. She is status post C5-6 and C6-7 anterior cervical discectomy and fusion with plating performed on 8/2/12. In an undated letter from the patient, she reported that cervical discectomy and fusion surgery had helped her for about two years, and then her pain returned. The patient endorsed neck pain radiating to the right upper arm with numbness from the elbow to the wrist. In a letter dated 11/3/17, the provider noted that the patient reported long-term intense neck pain rated as nine out of 10 with an Oswestry Disability Index of 56%. She had failed conservative treatment, including massage, physical therapy, cervical facet joint injections, Botox injections, and medications. The treatment plan included total discectomy, vertebroplasty, and artificial disc replacement at C4-5, C7-T1, and T1-2 with removal of the fusion plate. On 5/8/18, the patient underwent removal of a C5-7 plate, decompression of C4-5 and C7-T1, and implantation of a total disc prosthesis at C4-5 and C7-T1 for a diagnosis of degenerative vertical segmental instability at C4-5 and C7-T1. The patient received inpatient care from 5/7/18 through 5/11/18. Her post-operative course was noted to be uneventful. The patient has requested reimbursement for artificial disc replacement and related inpatient hospital stay that was provided from 5/7/18 through 5/11/18. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of the patient. At issue in this case is whether the requested artificial disc replacement and related inpatient hospital stay that was provided from 5/7/18 through 5/11/18 were medically necessary for treatment of the patients medical condition. Lu and colleagues noted that the traditional approach to treat multilevel cervical disc disease has been anterior cervical discectomy and fusion. The authors noted that there has been recent development of other surgical approaches to further improve clinical outcomes. Collectively, when elements of these different approaches are combined in surgery, it is known as hybrid surgery, which remains a novel treatment option. Lu and colleagues noted that there is a lack of robust clinical evidence supporting hybrid surgery for the treatment of multilevel cervical disc disease. Per the authors, future large prospective registries and randomized trials are warranted to validate the findings of this study. In this case, the patient underwent removal of a C5-7 plate, decompression of C4-5 and C7-T1, and implantation of a total disc prosthesis at C4-5 and C7-T1 for a diagnosis of degenerative vertical segmental instability at C4-5 and C7-T1. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the services at issue in this clinical setting. Therefore, artificial disc replacement and related inpatient hospital stay that was provided from 5/7/18 through 5/11/18 were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were 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.