Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and low back pain.

Treatment: Outpatient Neck Surgery 22551, 22552, 22845, 69990, 76000 each x 1; 22853 x 2.

The insurer denied coverage for Outpatient Neck Surgery 22551, 22552, 22845, 69990, 76000 each x 1; 22853 x 2.

The denial is upheld.
 

This is an adult patient who presented with chronic neck and low back pain, which radiates down both upper extremities and is associated with numbness. The patient recently developed hand clumsiness and imbalance. Prior treatment includes pain management and physical therapy. Neck surgery has been recommended. 
The chart shows the patient was seen by neurosurgery but it is unclear who saw the patient. The limited and somewhat disorganized submitted  documentation does not seem to support that the patient was actually seen and evaluated personally by the neurosurgeon.
There is no clear  date for magnetic resonance imaging (MRI) of the cervical spine which showed as per the impression-"multilevel degenerative changes throughout the cervical spine as described above level by level most significant at cervical (C)5-C6 with moderate to severe left-sided neural foraminal narrowing. There is no severe central or severe foraminal narrowing throughout the cervical spine levels."
The proposed surgery is at levels C4-C5 and C5-C6 with Anterior Cervical Discectomy and Fusion (ACDF) at C4-5-6.
No details regarding smoking status, or alternative measures have been provided. Procedure details could only be determined by provided surgical codes. 

On examination, there was no correlation between the subjective complaints and objective findings, as well as lack of significant findings on imaging which would necessitate the requested surgical procedure. Further, there was no indication of the patient's smoking status, informed consent, or details regarding the requested surgery. As such, the denial is upheld.

"Anterior cervical discectomy and fusion can be performed for a variety of pathologies but is most commonly used for the treatment of cervical radiculopathy or myelopathy. The procedure involves an anterior decompression of the disc space followed by interbody grafting and fusion. Supplemental anterior plating is commonly performed, and in certain circumstances, posterior instrumentation may provide additional fixation." (Rhee, J. M. et al. 2016).

"When selecting the specific surgical intervention for a patient with Degenerative cervical myelopathy (DCM), anterior (discectomy, corpectomy, hybrid discectomy/corpectomy), posterior (laminectomy and fusion, laminoplasty), and combined approaches may be considered as options depending on the specifics of the patient in question; evidence supporting each of these approaches is reviewed in detail. Recently developed clinical prediction models allow for accurate forecasting of postoperative outcomes, permitting enhanced communication and management of patient expectations in the preoperative setting. Finally, an overview of outcome measures recommended for use in the assessment of DCM patients is provided." (Wilson, J. R. et al. 2017).

"Conclusion: After adjusting for selection bias and patient risk factors, outpatient two-level ACDF was not associated with increased postoperative morbidity relative to inpatients, and may be considered in appropriately indicated patients." (Fu, M. C. et al. 2017). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Outpatient Neck Surgery 22551, 22552, 22845, 69990, 76000 each x 1; 22853 X 2 services is not substantiated.