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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for S1-2 anterior lumbar interbody fusion (ALIF) and right L5-S1 microdiscectomy (CPT 63030  laminectomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; CPT 22558  arthrodesis anterior interbody lumbar; CPT 20930  allograft for spine surgery only morselized; CPT 22614  arthrodesis, posterior or posterolateral technique, single level; and CPT 22612  arthrodesis posterior/posterolateral lumbar) with a two-day inpatient hospital stay. Campbell and colleagues reported a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Memtsoudis and colleagues concluded that despite being performed in generally younger and healthier patients, spinal fusion is becoming associated with increased morbidity. This patient is being treated for lumbar radiculopathy, L5-S1 herniated nucleus pulposus, sacroiliac (SI) joint dysfunction, and transitional lumbosacral anatomy. He presented with right S1 radiculopathy in the setting of a focal disc herniation. Physical examination revealed 5/5 strength in all myotomes tested. Sensation is intact to light touch in all dermatomes tested. On the SI joints maneuver test, the patient reported mild tenderness associated with FABER movement and compressive movements on the SI joint. However, there is a lack of detailed documentation of any instability on imaging studies. Furthermore, there are no demonstrated disc protrusions or large bony regions of neural compression to support a large and temporarily destabilizing decompression and fusion for this patient. The patients most recent physical examination findings did not demonstrate objective clinical findings of myotomal weakness, reflex loss, or sensory deficits to support a diagnosis of radiculopathy. In this clinical setting, there is a lack of medical indication for the requested spine surgery. Therefore, the requested S1-2 ALIF and right L5-S1 microdiscectomy (CPT 63030  laminectomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; CPT 22558  arthrodesis anterior interbody lumbar; CPT 20930  allograft for spine surgery only morselized; CPT 22614  arthrodesis, posterior or posterolateral technique, single level; and CPT 22612  arthrodesis posterior/posterolateral lumbar) with a two-day inpatient hospital stay is not medically necessary for 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.