Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lumbar fusion. 
 
You asked the Plan to pre-approve lumbar fusion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar fusion. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you present with chronic low back pain radiating to the bilateral anterior thighs. Signs/symptoms are consistent with neurogenic claudication. Significant functional limitations are noted in activities of daily living. Comorbidities include body mass index greater than 43. Clinical exam findings did not evidence any focal neurologic deficits. There is imaging evidence of moderate canal stenosis and mild neuroforaminal stenosis at L1/2, moderate to severe canal stenosis and moderate neuroforaminal stenosis at L2/3, severe canal stenosis and moderate left and moderate to severe right neuroforaminal stenosis at L3/4, severe canal stenosis and severe bilateral neuroforaminal stenosis at L4/5, and moderate to severe bilateral neuroforaminal stenosis at L5/S1. There is grade 1 anterolisthesis of L4 on L5 with no documentation of flexion/extension films showing instability. You have reportedly failed conservative treatment including physical therapy, medications, and epidural injection. Current evidence based medical literature would support decompression surgery for multilevel lumbar spine stenosis with fusion supported in the setting of instability or anticipated temporary intraoperative instability. It is reasonable that temporary intraoperative instability would occur at the L4/5 level due to prior surgical intervention at L4/5, anterolisthesis at L4/5, and plausible need for wide decompression given the severity of the stenosis at the surgical levels. You are aware of the surgical risks given your elevated body mass index, but there is documentation evidence of failed weight loss. You have a diagnosis, condition and symptoms that meet the Medicare criteria for coverage of lumbar fusion. Therefore, lumbar fusion would be considered the standard of care for the treatment of this enrollee's condition, and it would be considered medically reasonable and necessary for her to have a lumbar fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion have been met. Therefore, we decided that the Plan has to preapprove lumbar fusion.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.