Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 54-year-old male who presented to his provider on 3/11/22 with avascular necrosis 
of the left hip. The patient has requested reimbursement for inpatient  disc replacement, lumbar, 
from 11/8/22 through 11/9/22. The Health Insurer has denied this request and reported that the 
service at issue was not medically necessary for the treatment of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation does not support the medical necessity of the services at issue. Lumbar total disc 
replacement is a good surgical option for relatively young patients with discogenic low back pain 
with or without radiculopathy that is limited to one spinal level, and is more suitable for patients 
with discogenic lumbar pain. The procedure does not address posterior structures, which in this 
case are potential sources of pain and instability given the patients prior hemilaminotomy, so any 
posterior pain source, or severe stenosis as seen on MRI, is unlikely to resolve after total disc 
replacement. With severe boney stenosis, as in this patients case, preserving the segment motion 
with total disc replacement can induce more osteophytes and stenosis. Osteophyte production also 
places  the  patient  at  risk  for  development  of  heterotopic  ossification,  which  would  limit 
preservation of motion. In this case, the patient had multilevel degenerative disc disease with 
severe disc collapse at L4-L5 and L5-S1, and boney spinal stenosis at L5-S1 on MRI. The records 
noted that a CT scan reported the facet joints to be within normal limits. The patient received 
multiple steroid epidural injections every three months with limited relief and had avascular 
necrosis of his hip joint requiring total hip replacement, suggesting uncontrollable radicular 
symptoms by conservative measures. The patients multilevel lumbar spine degeneration with 
foraminal and boney lateral recess spinal stenosis, boney osteophytes, and ossified disc protrusion 
at L5-S1 resulted in severe lateral recess stenosis and impingement on the traversing left S1 nerve 
root. To achieve proper decompression of neural elements, particularly with this patients boney 
stenosis, adequate decompression of stenosis is likely to further destabilize the segment in a 
previously decompressed segment, and severe disc collapse is a relative contraindication for disc 
replacement. Additionally, posterior decompression is likely to be more effective than anterior 
discectomy. In this case, the nature of the pathology with multilevel disease was not the ideal 
indication for total disc replacement, particularly in the setting of required spinal fusion at the 
adjacent levels. In this clinical setting, given the patients prior decompression at L5-S1 and the 
amount of boney stenosis noted in the MRI, the service at issue was unlikely to provide adequate 
or lasting relief for the patient symptoms and was not medically indicated. Therefore, inpatient  
disc replacement, lumbar, from 11/8/22 through 11/9/22, was not medically necessary for the 
treatment of this patient.