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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for posterior spinal fusion at level L4-L5 and possibly each additional vertebral segment. Medical literature notes that, A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Researchers state, Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. Per authors, regarding lumbar fusion for stenosis with spondylolisthesis, The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this case, the patient is being treated for lumbar degenerative disc disease, with persistent low back pain. The patient was a high-level gymnast, and reported continued daily pain despite taking months off from doing gymnastics. She described the pain as constant, occasionally with some tingling down the back of the legs. On examination, the patient reported pain with bending backwards and forwards. Her strength and sensation were intact to the bilateral lower extremities. Her reflexes were noted as 1+ in bilateral brachioradialis and patellar. She had a normal gait. There was tenderness to palpation along the midline low lumbar spine. A straight leg raise was negative. Despite being requested, the submitted records did not include detailed documentation regarding the trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures, including injection therapies. Dynamic flexion/extension films did not corroborate instability of the lumbar spine, or instability at the requested surgical level, and the records did not document potential impending or inevitable temporary intraoperative instability. Therefore, posterior spinal fusion at level L4-L5, and possibly each additional vertebral segment, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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.