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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-level lumbar spinal fusion surgery (CPT code 22614) at L4-L5 and L5-S1.Researchers have concluded that lumbar fusion may be considered an option for patients with degenerative disc disease and disc herniations with radiculopathy when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. Authors have concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain that is refractory to nonsurgical care when a diagnosis of disc degeneration can be made. Studies recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population, however, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability.In this case, the patient presents with severe intractable low back pain radiating down the left leg to the ankle, with associated numbness and tingling in the L4-S1 dermatomal distribution. The patients history includes L4 and L5 laminectomy, with worsening radiculopathy over the past six months. The patients current functional limitations are documented in activities of daily living and work ability as a flooring contractor. Clinical exam findings have also documented sensory deficits, motor weakness, and reflex changes that are consistent with imaging evidence of advanced degenerative disc disease at L4-L5 and L5-S1, severe spinal stenosis at L4-L5, and significant lateral recess and neuroforaminal stenosis at L5-S1 with S1 nerve root compromise. The submitted records also include x-ray evidence of a grade 1 spondylolisthesis at L4-L5 with dynamic instability in extension. Records also include detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure. Current evidence based medical literature supports surgical intervention for the patients medical condition. He presents with severe and function-limiting low back pain and radiculopathy despite comprehensive conservative treatment. The patients signs, symptoms and clinical exam findings are consistent with imaging evidence of advanced degenerative disc disease and stenosis at the L4-L5 and L5-S1 level with nerve root compromise. The patients records also include evidence of dynamic instability at the L4-L5 level. Under these circumstances, the requested multi-level lumbar spinal fusion surgery (CPT code 22614) at L4-L5 and L5-S1 is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.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.