Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal - Back Pain
Surgical Services

The patient is a female with a several year history of cervical pain with associated headaches and radiation into bilateral arms. She also sees a pain management specialist for thoracic and lumbar pain. Apparently, she fell years ago (according to the letter she wrote for the appeal) and has had severe pain ever since in her neck and arms. The pain is described as 10/10 most days and increased with activity of any kind. No specific relieving factors are delineated. There are records of physical therapy (PT) sessions reporting continued neck pain, suboccipital headache and bilateral upper extremity numbness. The last PT note available  states her symptoms were increased following blowing leaves the day before. She underwent left ulnar nerve at the elbow and median nerve at the wrist releases with some improvement but continued bilateral arm symptoms. The PT note documents a normal exam however the provider note  reports decreased sensation in bilateral C8 and left C7 dermatomes with 4/5 strength bilateral intrinsic muscles. No upper motor neuron findings are recorded. There is note of a positive Tinels at the right wrist and elbow, with a positive Phalons at the right wrist. The provider recommended cervical discography but there is no record that this procedure was performed.
A cervical magnetic resonance imaging (MRI) reports disc desiccation at all levels with annular disc bulging C4-5 and C5-6 that indents the ventral spinal cord and smaller bulging C6-7 without report of spinal cord indentation. No signal change is reported at any level, no cervical deformity is reported, and all the above findings were unchanged compared to an MRI. A small subcutaneous fluid collection was noted in the suboccipital soft tissues, thought to be a possible sebaceous cyst, also unchanged from the prior MRI. Cervical x-rays from the same date report an unchanged osteophyte from the anterior C6, straightening of the normal lordosis and no instability with flexion/extension.
The provider's interpretation includes an impression of a kyphotic deformity at C5-6 but agrees no cord compression or signal changes.
An electromyography (EMG) reports mild right carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow.
Aside from the PT there is mention that she has had numerous injections although the only documented injections in the records provided were bilateral L3-4, L4-5 and L5-S1 facet injections. There is a notation in the pain management physician's record that a cervical spinal stimulator was implanted at some time in the past but had to be removed for a staph infection. She is a current everyday smoker/vaper.
The subject under review is the medical necessity for the C4-C7 anterior cervical discectomy and fusion (ACDF).

The health plan's determination is upheld.

No, the requested procedure of an ACDF C4-C7 is not considered medically necessary for this patient at this time. This patient appears to have predominantly axial neck pain and headaches without a clinical radiculopathy or myelopathy, either on exam or on imaging studies. The complaints of radiation into bilateral upper extremities with numbness and tingling is not explained on her current imaging studies. While there is robust support in the literature for surgical intervention for refractory cervical radiculopathy or symptomatic myelopathy (see references listed below), there is a paucity of literature on the procedure for axial neck pain alone in the absence of instability or deformity. The literature source most often cited in regard to ACDF for axial neck pain in the absence or radiculopathy is Kiew et al., who reported on a systemic review of the current literature regarding this subject and concluded there was only low-grade evidence that patients may receive some improvement in pain and function following ACDF. In addition, even in patients with imaging evidence of some degree of spinal cord compression without clinical myelopathy current guidelines recommend against surgery. (Fehlings et al).