Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Back Pain

Treatment: Decompression and fusion of the lowermost segment of the back

The insurer denied coverage for decompression and fusion of the lowermost segment of the back

The denial is overturned

This is an adult patient. Lumbar (L) 5 - sacral (S) 1 anterior lumbar interbody fusion (ALIF) and posterior fusion is requested by the treating provider. The patient's provider noted the patient had chronic back pain and left leg pain and magnetic resonance imaging (MRI) that showed retrolisthesis. Decompression and fusion were recommended. Lumbar computed tomography (CT) confirmed L5 sacralized vertebra and retrolisthesis at L4-5. A lumbar MRI confirmed retrolisthesis at L4-5, with thecal sac impingement and foraminal stenosis that had progressed. Electromyography (EMG) confirmed ongoing L5 radiculopathy.

According to Mobbs, R. J. et al. (2016), "From the 227 ALIF cases, mean operative blood loss was 103 milliliters (mL), ranging from 30 to 900 mL. Mean operative time was 78 minutes. The average length of stay was 5.2 days. Intraoperative vascular injury requiring primary repair with suturing occurred in 15 patients (6.6%). There were 2 cases of postoperative retroperitoneal hematoma. Three patients (1.3%) had incisional hernia requiring revision surgery; 7 (3.1%) patients had prolonged ileus (>7 days) managed conservatively. Four patients described retrograde ejaculation. Sympathetic dysfunction occurred in 15 (6.6%) patients. There were 5 (2.2%) cases of superficial wound infection treated with oral antibiotics, with no deep wound infections requiring reoperation or intravenous therapy. There were no mortalities in this series... Conclusions: ALIF is a safe procedure when performed by a combined vascular surgeon and spine surgeon team with acceptably low complication rates. Our series confirms that the team approach results in short operative times and length of stay, with rapid control of intraoperative vessel injury and low overall blood loss."  

Bydon, M., Alvi, M. A., & Goyal, A. (2019) write, "Degenerative lumbar spondylolisthesis is one of the most common causes of low back pain and is defined as displacement of one vertebra over subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring. Understanding natural history of degenerative spondylolisthesis is important to tailor an individualized management plan for each patient. 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."

The patient has a sacralized L5 vertebra and therefore the MRI report mentions retrolisthesis and facet arthropathy at L4-5 which is labeled L5-S1 by the treating provider. As noted by the provider, the patient has degenerative findings and severe radiculopathy; decompression alone will place the patient at risk for iatrogenic instability. The records confirm that decompression and fusion at the level labeled L4-5 in the MRI report is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for decompression and fusion of the lowermost segment of the back is substantiated.