Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lower Back Pain. 

Treatment: Inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L [lumbar] 5 to S [sacral] 1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)). 

The insurer denied coverage for inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L5 to S1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)). 

The denial is overturned. 

This patient is a healthy female who has failed conservative multi-modal nonoperative treatment for months, including documentation of a physical therapy/rehabilitation program, pain management, injections, and active exercise. In addition, this patient does not have any documented contraindications to lumbar disc replacement. Contraindications to lumbar artificial total disc replacement include but are not limited to the following: Moderate or severe facet arthropathy or pars defect at the operative level on a preoperative MRI (Magnetic Resonance Imaging) scan, CT (Computed Tomography) scan or plain radiograph; Lumbosacral spinal fracture; Scoliosis of the lumbosacral spine; Active systemic infection or infection localized to the site of implantation; Tumor in the peritoneum, retroperitoneum or site of implantation; Osteoporosis or osteopenia as defined by recent (within one year) DEXA [dual energy x-ray absorptiometry] ( scan; Isolated radicular compression syndromes, especially due to disc herniation; Spinal stenosis or radiculopathy. 

Compared to the alternative of lumbar spinal fusion, multiple nationally and internationally recognized societies recommend lumbar spinal disc replacement in select patients. This includes the International Society for the Advancement of Spine Surgery (ISASS) and the North American Spine Society (NASS). A 2021 ISASS Policy Statement concludes that both cervical and lumbar total disc replacements, including multi-level use as approved by the FDA (Food and Drug Administration), are safe and effective treatment alternatives to fusion for patients meeting well established selection criteria. While A 2019 NASS Coverage Policy Recommendation states that lumbar artificial disc replacement is indicated for patients with discogenic low back pain who meet all of the following criteria: Symptomatic single level lumbar disc disease at L3-L4, L4-L5 or L5-S1 level; Presence of symptoms for at least 6 months or greater and that are not responsive to multi- modal nonoperative treatment over that period that should include a physical therapy/rehabilitation program but may also include (but not limited to) pain management, injections, cognitive behavior therapy, and active exercise programs; Any underlying psychiatric disorder, such as depression, should be diagnosed and the management optimized prior to surgical intervention; Primary complaint of axial pain, with a possible secondary complaint of lower extremity pain. 

The carrier's denial of one inpatient day and related low back surgery (lumbar spinal bone five to sacral spinal bone one (L5 to S1) spinal disc replacement and any associated services, procedures or devices) (procedure code 22857: total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar and procedure code 95940: continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (list separately in addition to code for primary code)) should be overturned. It is more beneficial than any other standard treatments.