Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive neurologic deficit, Motor weakness in the left biceps and triceps, Left arm pain and paresthesia into the index finger and thumb

Treatment: Cervical fusion, including: CPT code 22551, CPT code 22552, CPT code 22845, CPT code 22853, CPT code 20930, and CPT code 20936

The insurer denied coverage for Cervical fusion, including: CPT code 22551, CPT code 22552, CPT code 22845, CPT code 22853, CPT code 20930, and CPT code 20936.

The denial is overturned.

This is a male patient who was seen at an office visit with a chief complaint of radiating left arm pain and paresthesia into the index finger and thumb which began 3 weeks prior. He had been utilizing Tylenol as well as Percocet and Advil. Due to ongoing symptoms, the patient has been referred for further evaluation. 

The patient has previously requested surgical intervention. However, it has been denied. Since this patient's last evaluation, the patient has attempted to modify his activity. He has not been able to resume exercise and has trialed various medications but, none of which have given him relief. The patient's physical examination revealed tenderness to the cervical paraspinals. The patient had 4/5 weakness to the left biceps, which was slightly worse when compared to prior exam. There was persistent 4/5 weakness of the triceps and a markedly positive Spurling's. The patient's physician detailed that the patient has had ongoing symptoms for over 3 months. The patient participates in physical therapy and has trialed injection as well as multiple medications. The patient's physician referenced prior imaging and recommended that the patient undergo surgical intervention. The patient's magnetic resonance imaging (MRI) of the cervical spine reveals a moderate sized diffuse disc osteophyte complex at cervical vertebrae (C)5-6 and C6-7 level, resulting in mild spinal canal stenosis with moderate to severe C5-6 and mild C6-7 left-sided foraminal encroachment. There is also a small diffuse disc osteophyte complex asymmetric towards the right at C3-4 and C4-5, resulting in moderate C3-4 and mild C4-5 right-sided neuroforaminal narrowing. The request has been received for a C5-C7 anterior cervical discectomy and fusion with placement of biomechanical cages as well as autograft and allograft.

Based on the review of the medical record, the patient has a progressive neurologic deficit, motor weakness in the left biceps and triceps, persistent sensory symptoms (pain and paresthesia), which has failed to respond to more than 3 months of multimodal conservative management. Given the presence of C6 and C7 nerve root encroachment on recent imaging, the literature review indicates that the likelihood that this patient's symptoms will resolve without surgery is unlikely. Therefore, the proposed C5-6 and C6-7 anterior cervical discectomy and fusion meets medical necessity and would be standard of care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
 
The carrier's denial of cervical fusion as not medically necessary, including: CPT code 22551, CPT code 22552, CPT code 22845, CPT code 22853, CPT code 20930, and CPT code 20936 should be overturned. The medical necessity is substantiated.