Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lower Back Pain. 

Treatment: Inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L [lumbar] 5 to S [sacral] 1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)). 

The insurer denied coverage for inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L5 to S1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)). 

The denial is overturned. 

This female has a history of lower back pain. She presented to the Neurosurgeon's office for a follow up for lower back pain. Imaging revealed grade 4 circumferential annular tearing at L5 with mild intervertebral disc space narrowing. There was no spinal canal foraminal stenosis. She had piriformis release in the past. She had undergone injections with no long-term pain relief. She tried physical therapy (PT) and medications without relief. The request is for single level artificial disc replacement. 

Formica et al. (2020) (2) conducted a retrospective case series of 32 patients who underwent TDR [total disc replacement] for low back pain from degenerative disc disease (DDD) resistant to conservative treatment. Demographic features, surgical data, clinical and radiographic outcomes, complications and spinopelvic parameters were evaluated. The mean follow-up was 164 36.5 months. The clinical outcomes measured by visual analogue scale and Oswestry Disability Index showed a significant improvement between preoperative and 1-year follow-up (P < 0.01). No significant temporal variance had been identified between 1-year and long-term follow-up (P> 0.05). The surgical revision rate was 10% [percent]. The overall rate of complications was 20%. At final follow-up, the mobility of the prosthesis was preserved in 68.75% of the cases, and 73.3% of the patients were globally well aligned. The authors concluded that the long-term results confirmed the existing evidence about efficacy and safety of TDR as a reliable option, in optimal surgery indication, to treat DDD. 

This procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of one inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L5 to S1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)) should be overturned. It is more beneficial than any other standard treatments.