Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery, cervical posterior decompression and fusion at C4-7. This patient presents with neck pain and stiffness, with numbness and tingling of trapezius. She denies radicular and myelopathy symptoms. In addition, there are no signs of myotomal findings compatible with a diagnosis of cervical radiculopathy or cervical myelopathy. The patients medication list does not document that she has exhausted an adequate trial of analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). Further, there is no documentation of manipulation, home exercise program, epidural steroid injections, or nerve root blocks. There is documentation of only two physical therapy visits and a two-level facet block. She is employed full time, yet there is no documentation of pain affecting her activities of daily living or causing functional limitations. Except for diminished range of motion in her neck, she has maintained normal motor and sensory examinations. The physical examinations did not include neck lymph node or axillary examinations or Tinels sign. Thus, all pain generators have not been adequately defined or treated. She is status post ACDF and left C6 laminotomy. Her imaging shows adjacent segment abnormal findings. However, there is no correlation of her imaging with her clinical examination and there is no history of progressive neurologic deficits. Given these findings, the patient does not meet the current criteria for the requested surgical intervention. The patients records do not establish a diagnosis of cervical radiculopathy, cervical myelopathy, or progressive neurological deficit. Imaging does reveal evidence of nerve root compression, but this has not been correlated with the patients clinical examination. Moreover, the patient has not failed at least six weeks of conservative management and her pain has not been reported to affect her ability to perform activities of daily living or cause other functional limitations. Overall, the patients pain generators have not been adequately defined and treated. Thus, she fails to fulfill the criteria for ACDF and posterior spinal fusion. The proposed ACDF and posterior spinal fusion is not medically necessary since it is not in accordance with generally accepted standards of medical standards and is not consistent with the patients symptoms and diagnosis. Accordingly, the requested back surgery, cervical posterior decompression and fusion at C4-7 is not medically necessary for treatment of this patients cervicalgia. Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.