Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Herniated Disc

Treatment: Back surgery (procedure codes 22588, 63030, 63047, 63272, and 22612) and a hospital admission

The insurer denied coverage for back surgery (procedure codes 22588, 63030, 63047, 63272, and 22612) and a hospital admission.

The denial is upheld.

This is the case of an adult male patient with history of gastroesophageal reflux disease (GERD), herniated disc, hiatal hernia, hypertension, sciatica, scoliosis, varicella, and obesity. He presented to the hospital for a scheduled pedicle screw fixation Medtronic voyager L (lumbar) 4-L5, allograft augmented posterior spinal fusion L4-L5, navigation assisted spinal instrumentation with DuPuy VIPER prime system (technique for percutaneous pedicle screw placement), placement of right iliac crest percutaneous reference pin, computed tomography (CT) and magnetic resonance imaging (MRI) guided right foraminotomy with partial facetectomy, allograft augmented posterior spinal fusion L4-L5, and neurolysis of L4-L5 right. General anesthesia was used for the 6.5-hour surgery. The patient was admitted for postoperative care. He was placed on gastrointestinal (GI) prophylaxis and a bowel regimen. The patient was educated on use of an incentive spirometer. Perioperative antibiotics were given as per Orthopedic surgery recommendations. The patient tolerated physical therapy (PT) and achieved all necessary goals for discharge. Pain was well controlled. The patient was able to void freely and pass flatus. Labs and vital signs were stable. He was discharged.

The patient had undergone a previous decompression. There were reported complications of infection. He required additional surgery. His physician reported concern of the disc and additional collapse. 

A fusion is a procedure performed for instability to spinal elements. There should be documentation of abnormal motion on flexion extension views or presence of underlying abnormality such as spondylolisthesis/pars defect. On rare occasions it is indicated for severe discogenic disease. On occasion if a wide decompression is being performed removal of excess posterior elements can result in increased laxity. 

The records report the patient has had continued pain despite all courses of treatment. There were no flexion extension views nor report of removal of posterior elements to result in instability. Documentation noted lateral listhesis secondary to collapse but no other instability patterns. 

In a discussion of the role of lumbar fusion, Up to Date stated:

"A variety of fusion techniques are practiced. All involve the placement of a bone graft between the vertebrae. Fusion can be performed with or without supplemental hardware (instrumentation), such as plates, screws, or cages, that serve as an internal splint while the bone graft heals. Fusion alters the normal mechanics of the spine and is associated with an increase in long-term degenerative changes in adjacent spine segments.

A systematic review of four randomized trials found that disability outcomes between lumbar vertebral fusion and nonsurgical treatment did not meet US Food and Drug Administration (FDA) criteria for clinically meaningful differences."

A recent review by Zhao, et al came to a similar conclusion: "The evidence for surgical fusions and disc replacement is similar, without superiority when compared with multidisciplinary biopsychosocial rehabilitation, well-designed physical therapy, or epidural injections."

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

Back surgery and a hospital admission is not considered medically necessary for this patient.

The insurer's denial of coverage for back surgery (procedure codes 22588, 63030, 63047, 63272, and 22612) and a hospital admission is upheld. Medical necessity is not substantiated.