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 upheld. 

This is a female with 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. She had undergone injections with no long-term pain relief. She tried physical therapy (PT) and medications without relief. 

There are several references and Guidelines which describe an improvement in health outcome. Disc replacements for lumbar disease have been recognized as an alternative in the management of disc disease.  The FDA (Food and Drug Administration) had granted approval for premarketing. There was no recommendation with regard to benefit nor specific use. 

This patient has no defined pain generator. The records show she had received treatments for many years. She had undergone pyriformis surgery, ESI (epidural steroid injection), hip injections, Prolotherapy, dry needling and chiropractic. The report of L5-S1 disc space being causative is of low credence. The L5-S1 disc was reported to have concordance on discogram. The records show the L4-5 space had a VAS (visual analog scale) of 3 while the L5-S1 had VAS of 5. The MRI (Magnetic Resonance Imaging) was quite dramatic showing annular tear at L3-L4 with no tears to L4-L5 and L5-S1. Simply stated surgery based on a single level VAS of 5 without a real control has no clinical correlation. It is unclear whether L3-4, L4-5 or L5-S1 is the pain generator. Performing a major reconstructive procedure with the above information has no justification. 

This is not the best available treatment for this patient at this time. There is no defined pain generator. Treatments have been provided to the SI joint, pyriformis, disc, soft tissues and hip. 

The adverse risks are increased over standard treatment/services. It is difficult to revise a lumbar disc replacement. The surgical approach is anterior. Removal of the device has a very high complication rate. 

The requested service is not 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 upheld.