Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Lower back surgery - spinal fusion
The insurer denied lower back surgery - spinal fusion.
The determination is upheld.

The patient has right sided axial back pain radiating to the right hip and right thigh. He reports 85% low back pain compared to the right leg pain. The pain is constant. He has tried more than 6 weeks of physical therapy as well as an extensive home exercise program. He has been taking ibuprofen for more than 6 weeks without improvement. He had a few right lumbar (L) 4-5 facet joint injections which provided 70% relief from the lidocaine portion and underwent a right L4-5 radiofrequency ablation which gave him a few days of relief of approximately 50 to 60%. His pain is 7 out of 10. He has also tried chiropractic treatment and activity modification without relief. A magnetic resonance imaging (MRI) scan shows multilevel degenerative disc disease, right facet arthrosis with associated subchondral marrow edema pattern at L4-5 without spinal stenosis, disc herniation, or nerve root impingement at other levels. An MRI of the lumbar spine shows at L5-sacral (S) 1 a tiny central disc protrusion with no stenosis or nerve root sleeve compression. All other levels are normal. Radiographs show multilevel degenerative disc disease present at L4-5 and L5-S1 with maintained alignment and no instability and facet joint arthrosis. The physical examination shows normal sensation throughout and normal reflexes bilaterally. There is 5 out of 5 strength in bilateral lower extremities. There are no other documented neurological abnormalities present. There is no numbness tingling or weakness documented. The plan is for a right L4-5 facetectomy with posterior spinal fusion with percutaneous pedicle screws using bone morphogenetic protein (BMP) as an autograft will not be available.

At issue is the medical necessity of lower back surgery - spinal fusion.

As per the radiographic studies, there is multilevel degenerative disc disease at L4-5 and L5-S1 with maintained alignment and no instability and facet joint arthrosis. The MRI of the lumbar spine shows a tiny central disc protrusion with no stenosis or nerve root sleeve compression at L5-S1. Therefore, the patient does not meet the requirements for surgical intervention in the form of the requested current procedural terminology (CPT) codes.

The requested procedure is not medically necessary.

Based on current standards for lumbar spine fusion, the patient does not have any abnormal neurologic or physical exam findings present as per the documentation submitted for review. There is also a lack of correlation of the patient's symptoms and the radiographic imaging and studies submitted for review. The most recent MRI documents the L4-L5 level to be normal without any pathology noted. Therefore, based on the patient's physical examination findings and radiographic/MRI imaging findings submitted for review, the request would not be considered medically necessary per current standards.

The articles cited as per Reid, Yavin, and Perolat outline the current consensus among orthopedic and neurological surgeons with respect to lumbar fusion indications. The indications are based on the patient's symptoms, exam findings, correlation of symptoms with imaging and exam findings, and the overall health/function of the patient. The patient did not meet the current standard of care guidelines of medical necessity.