Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Surgery (current procedural terminology [CPT] code 63047). 
The insurer denied coverage for surgery (CPT code 63047). 
The denial is upheld. 

This case involves a patient with a subject for review for the denial of coverage for surgery (current procedural terminology [CPT] code 63047). 

When the patient presented for an initial exam, they stated that when they were walking a few weeks prior to presentation, they suddenly experienced low back pain and pain anteriorly down to the right lower extremity (RLE). The patient described cramping in their right hip and also a right foot drop. The patient has failed oral prednisone as well as gabapentin. 

Magnetic resonance imaging (MRI) of the Lumbar Spine revealed Grade 1 posterior listhesis L (lumbar) 2-L3 due to spondylosis, broad-based disc protrusion L4-L5 that resulted in central canal stenosis, lateral recess narrowing and neuroforaminal narrowing. Spondylosis and disc bulging L3-L4 with central canal stenosis, lateral cyst narrowing and neuroforaminal narrowing, spondylosis and disc bulging and posterior listhesis L2-L3, spondylosis and disc bulging L1-L2 and L5-S (sacral) 1. 

The patient was seen for back pain. The patient reported lumbar spine (LS) pain with radiculopathy into RLE, and felt like there is a knot in the LS. The patient also reported sharp pain on their foot. The patient's pain was alleviated with walking and the patient has been utilizing at home physical therapy and stretching for pain management. 

The patient was seen and was scheduled for right microdiscectomy. Electromyography (EMG) showed bilateral S1 and right L5 radiculopathy, and mild bilateral carpal tunnel syndrome. 

The patient underwent right L4-L5 hemi laminectomy, diskectomy, and foraminotomy on for the diagnosis of herniated disc, stenosis, and spondylosis L4-5. 

The patient presented for post-op follow up and stated that they felt no pain until one day prior. The patient stated that they felt like the muscles were throbbing in their bilateral hips and bilateral lower extremities (BLE). During the visit, the patient reported 90% relief from surgery. 

The case was previously denied due to the lack of imaging performed within the past six months and treatment for six weeks. The medical records received for this review includes an MRI of the lumbar spine done and revealed Grade 1 posterior listhesis L2-L3 due to spondylosis, Spondylosis and broad-based disc protrusion L4-L5 that resulted in central canal stenosis, lateral recess narrowings and neuroforaminal narrowings, spondylosis and disc bulging L3-L4 with central canal stenosis, lateral cyst narrowings and neuroforaminal narrowings, spondylosis disc bulging and posterior listhesis L2-L3, spondylosis and disc bulging L1-L2 and L5-S1 and distal spinal cords pathology not seen. Although it was noted during the visit that the patient has failed oral prednisone as well as gabapentin under the direction of the primary care provider and has been utilizing at home physical therapy and stretching for pain management during the subsequent visit, it is not confirmed that he completed 6 weeks to 3 months of conservative treatment. As such the denial of coverage for surgery (CPT code 63047) provided is upheld and is considered not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for surgery (CPT code 63047) is not substantiated.