Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 42-year-old female who presented to her provider on 11/30/21. The patient has 
requested authorization and coverage for back surgery. The physician reviewer found that at 
issue is whether back surgery is medically necessary for the treatment of this patient. The 
submitted documentation does not support the medical necessity of the requested service. 
Bydon and colleagues note, 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. 
Chan and colleagues state, Patients with symptomatic lumbar spondylolisthesis may first be 
treated with conservative management strategies including, but not limited to, non-narcotic and 
narcotic pain medications, epidural steroid injections, transforaminal injections, and physical 
therapy.  For  well-selected  patients  who  fail  conservative  management  strategies,  surgical 
management is appropriate. Resnick and colleagues explain, As a result of the decompression, 
the inherent instability associated with the spondylolisthesis may progress and lead to further 
misalignment  that  results  in  pain  or  recurrence  of  neurological  complaints.  Under  these 
circumstances,  lumbar  fusion  is  considered  appropriate  to  stabilize  the  spine  and  prevent 
delayed deterioration. Eismont and colleagues note, Lumbar degenerative spondylolisthesis 
(DS) is  a  common  cause  of  low back  pain,  radiculopathy,  and/or  neurogenic  claudication. 
Treatment begins with a trial of nonsurgical methods, including physical therapy, nonsteroidal 
anti-inflammatory drugs (NSAIDs), and epidural corticosteroid injections. Surgical treatment with 
decompression and fusion is recommended for patients who do not respond to this initial 
regimen.  Although  much  has  been  published  in  the  past  two  decades  on  the  surgical 
management of DS, the optimal method remains controversial. Interbody fusion may improve 
arthrodesis rates and can be performed via numerous surgical approaches. Minimally invasive 
techniques continue to be developed. Particular attention to surgical management of DS in the 
elderly is warranted given the increasing numbers of elderly persons. Healthcare utilization in the 
future must take into account evidence-based medicine that establishes clinically effective 
practices  while  simultaneously  being  cost  effective.  Ghogawala  and  colleagues  conclude, 
Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion 
to laminectomy was associated with slightly greater but clinically meaningful improvement in 
overall physical health-related quality of life than laminectomy alone. In this case, the patient 
presented with chronic and ongoing low back pain for the past two and a half years, rated at nine 
out of ten on the VAS. She had numbness and weakness in her buttocks and thighs, and difficulty 
walking across a room without stopping and resting. An examination showed her in mild distress 
from her back and leg pain. She had diminished sensation in the left S1 distribution, an absent 
left  heel  reflex  and  trace  reflex  on  the  right,  and  strength  noted  at  5-/5  diffusely.  Her 
thoracolumbar motion was diminished. She had pain with both flexion and hyperextension as 
well as with the initiation of extension. She had pain in the lumbosacral junction in the midline 
and the paraspinal region at the lumbosacral junction, along with mild greater trochanteric 
tenderness. However, the submitted records did not include dynamic flexion/extension films to 
potentially assess the amount of movement or instability at the requested surgical level. Given 
that  the  submitted  documentation  did  not  detail  evidence  of  the  potential  of  impending/inevitable temporary intra-operative instability, or of the trial and failure of a full 
course of physical therapy for the lumbar spine, the requested service is not medically indicated. 
Therefore, back surgery is not medically necessary for the treatment of this patient.