Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve L5-S1 anterior lumbar interbody fusion. 
 
You asked the Plan to pre-approve L5-S1 anterior lumbar interbody 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 L5-S1 anterior lumbar interbody fusion. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee presents with progressively worsening back pain radiating into 
the bilateral lower extremities, left greater than right, with weakness and numbness. Functional limitations are 
noted in activities of daily living. Clinical exam findings have evidenced motor and sensory deficits consistent 
with significant L5/S1 disc space collapse with osteophyte formation and vacuum disc phenomenon and left-
sided unilateral pars defect (spondylolysis). The enrollee is status post L2-L5 extreme lateral interbody fusion 
(XLIF) on November 27, 2018, and L2-L5 laminectomy with fusion on December 4, 2018. The enrollee has 
failed to improve with conservative treatment, including activity modification, medications, physical therapy, 
bracing, cane, and lumbar epidural steroid injections. Current evidence based medical literature supports 
surgical in this enrollee's clinical setting. There is progressively worsening radicular low back pain with focal 
motor and sensory deficits. The enrollee has failed long-term conservative treatment. There is evidence of disc 
collapse at the L5/S1 level adjacent to prior 3-lumbar lumbar fusion and in the setting of unilateral pars defect. 
There is evidence that sufficient decompression that would result in plausible temporary intraoperative 
instability and necessitate fusion. Therefore, this enrollee has a diagnosis, condition and/or symptoms that meet 
Medicare criteria for the requested lumbar spine fusion. The requested lumbar fusion would be considered the 
standard of care and medically reasonable and necessary for the treatment of this enrollee's condition. 
 
Review of the file shows that the plan uses Local Coverage Determination, LCD L37848 to support their 
denial. However, LCD L37848 is not valid for the enrollee's home state. Therefore, we cannot use 
LCD L37848 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5-S1 anterior lumbar interbody fusion have been met. Therefore, we decided 
that the Plan has to pre-approve L5-S1 anterior lumbar interbody 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.