Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2
A 35-year-old male enrollee has requested authorization and coverage for spine fusion extra segment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient is a 35-year-old male with a history of low back pain.  On 1/07/15, the patient reported low back pain that radiated to the right lower extremity down to the foot associated with numbness and tingling.  He complained of right lower extremity weakness and was walking with a cane for stability.  The patient was also noted to have undergone L4-5 discectomy in 2013. On physical examination, it was noted the patient had muscular strength measured at 5/5 throughout the bilateral upper and lower extremities.  Sensory was intact to light touch to the bilateral upper and lower extremities.  Reflexes were symmetric at 2/2 and symmetrical bilaterally.  On 2/09/15, the patient reported low back pain radiating down the right lower extremity of approximately three months duration.  The records noted that epidural steroid injections provided no significant benefit and that the patient was currently participating in physical therapy program that was also not providing significant relief. On physical examination, the patients lumbar spine was non-tender to palpation.  There was no evidence of paraspinal muscle spasms.  The patients strength was 5/5 and equal bilaterally and sensation was intact.  Deep tendon reflexes were measured 2+ and symmetrical.  On 2/19/15, computed tomography (CT) scan of the lumbar spine revealed mild annular bulge at L4-5 without focal herniation, spinal stenosis or significant foraminal stenosis and right L5-S1 herniated disc to the right.  The provider reported that due to evidence of significant degenerative changes and signs of potential instability at L4-5, it was recommended that the L4-5 be included with the previously approved single level fusion at L5-S1.  The patient has requested coverage for spine fusion extra segment.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. In this case, the superior effectiveness of the requested services has not been established.  The documentation provided indicated that the patient had significant degenerative changes and slight spondylolisthesis at L4-5 and has potential for instability.  However, the magnetic resonance imaging (MRI) and CT scans provided for review failed to demonstrate these findings.  Additionally, there is a lack of evidence that the patient has significant instability at the L4-5 level, and performing a fusion surgery for potential instability is not appropriate. Furthermore, multilevel fusion for the treatment of degenerative disc disease is not currently recommended.  Therefore, the requested spine fusion extra segment is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.