Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spinal nerve root compression 

Treatment: ambulatory C5-C6 anterior cervical disc fusions (ACDF), 22853 x1 Synthetic Cage, 22551 x1 Anterior Cervical Discectomy and Fusion, 22845 x1 Anterior instrumentation; 2 to 3 vertebral segments and 63075 x1 Discectomy, anterior, with decompression, cervical, single interspace

The insurer denied the ambulatory C5-C6 anterior cervical disc fusions (ACDF), 22853 x1 Synthetic Cage, 22551 x1 Anterior Cervical Discectomy and Fusion, 22845 x1 Anterior instrumentation; 2 to 3 vertebral segments and 63075 x1 Discectomy, anterior, with decompression, cervical, single interspace.

The denial was upheld.   

This female patient has a history of chronic neck and left arm/hand pain. The patient's cervical magnetic resonance imaging (MRI) showed multiple levels of right sided nerve root compression at C3-4, C4-5, C5-6 and C7-T1 and left nerve root compression at C5-6 due to foraminal bony productive change and C7-T1 due to mild left facet arthropathy. The patient was followed by Neurosurgery for C6-radiculopathy. The patient was working light duty and was not a smoker. The patient's exam noted weakness of the left wrist dorsiflexor 4/5 and decreased sensation to pinprick and light touch in the left C6 distribution. There was an absent left brachial radialis reflex. The patient was viewed to be in excessive discomfort. The plan was for an anterior cervical disc fusion (ACDF) at C5-6. The patient had 12 visits of physical therapy. The patient's neck pain was improving and she was adhering to her home exercise program. The patient was functionally limited in self-care. The patient's initial exam noted reduced cervical range of motion and weakness in shoulder flexion and abduction 3+/5. The patient's Neck Disability Index score was 54%.

According to the literature, non-operative treatment of cervical radiculopathy consists of a number of different modalities including immobilization, physical therapy, traction, manipulation, medication, and cervical steroid injection. Studies have reported good to excellent outcomes in up to 90 % of patients with non-operative management of cervical radiculopathy. Oral analgesic medications are commonly used in managing patients for cervical radiculopathy. There are two broad categories of medications that may be considered: narcotic and non-narcotic medications. When possible, the use of narcotic medications should be avoided as they can have consequential side effect and prolonged use can lead to dependency and can make postoperative analgesia more challenging. However, if the patient's pain at presentation is poorly controlled, a short course of oral narcotics can be beneficial. Of the non-narcotic medications, non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of management. NSAIDs have both analgesic and anti-inflammatory effects and provide relief by targeting the inflammatory cascade at the nerve roots. Oral corticosteroids (a week-long methylprednisolone taper) are sometimes used in the acute phase to manage the inflammatory cascade. However, there is no evidence to support their efficacy for this indication, and their use must be weighed against the risk of complications such as hyperglycemia, osteonecrosis, and infection.

There are no strict guidelines on the indications for surgery in cervical spondylosis. The decision to proceed with surgery is taken after detailed consultation, physical examination, and imaging and is based on a number of variables including the severity of symptoms, duration of symptoms, progression of symptoms, radiological changes, and the patient's fitness for surgery. The failure of conservative management strategies, such as physiotherapy, analgesia, nonsteroidal anti-inflammatory drugs, and epidural injections, is another indication for surgical intervention. 

Based on the review of the medical record and literature, the anterior cervical disc fusion (ACDF) was not medically necessary for this patient. The patient has not been evaluated after her physical therapy to determine if she was having ongoing pain and neurological deficits. As of her last therapy note, the patient had improvement in her neck pain. It is also unclear that the patient has been treated with medications for at least six weeks. Literature review supports conservative management, and considers surgical intervention if the patient fails conservative management. However, in this case, it is unclear that this patient has failed conservative management. Thus, the surgical intervention is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the request for ambulatory C5-C6 ACDF, 22853 x1, 22551 x1, 22845 x1 and 63075 x1 is not substantiated.  The insurer's denial should be upheld.