Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain.

Treatment: neck surgery (procedure codes 22551, 22552, 22853, 20937, 20930, and 20939).

The insurer denied coverage for neck surgery (procedure codes 22551, 22552, 22853, 20937, 20930, and 20939).

The denial is upheld.
 

This is an adult with a history polycystic ovarian syndrome (PCOS), hypertension, peripheral neuropathy, and vertigo. The patient had a video visit with the Pain Management physician's office for an evaluation of neck pain. It radiates to the shoulder and chest. The duration was years. 

A physical examination showed spasm and normal strength. The magnetic resonance imaging (MRI) showed multilevel disc protrusions, annular fissure and degenerative changes. There was neuroforaminal stenosis. Flexion extension views showed a trace of listhesis of cervical (C)3-4. 
She was evaluated by a neurosurgeon who reported a diagnosis of dynamic instability to C3 and C4.

The pain is improved with Tylenol, Motrin, heat, and massage. The patient participated in physical therapy (PT). The patient has tried pain medications and epidural steroid injections (ESIs). The patient is scheduled for surgery.  

Surgical indications require definition of the pain generator. There should be failure to improve with conservative treatment.  The facts were that no specific pain generator has been defined. There were no positive findings on physical examination. There were no positive image studies for nerve root compression or the reported "instability". The treatments provided were ESI on three occasions. There was no documentation from PT in the past year, chiropractic, traction or other non-steroidal anti-inflammatories (NSAID's) (reported medication was Motrin) were tried. 

Based upon the above, surgery would not be indicated.

See AIM Clinical Guidelines for Cervical radiculopathy or instability: 

Cervical decompression with or without fusion is considered medically necessary to treat ANY of the following conditions: Instability; Instability of the cervical spine due to ANY of the following conditions, where instability is caused by the condition itself, or when treatment of the condition is anticipated to result in instability (i.e., resection or debridement): tumor of the spine or spinal canal, n/a, infection (osteomyelitis, discitis, or spinal abscess), n/a, fracture or dislocation (may be traumatic or pathologic), n/a, nontraumatic atlantoaxial (C1-C2) instability or subluxation (greater than 5 millimeters (mm) as documented by imaging) in ANY of the following: connective tissue disorders such as rheumatoid arthritis, Os odontoideum, n/a, and skeletal dysplasia, n/a.
Symptomatic, non-traumatic cervical spondylosis as demonstrated by EITHER of the following radiographic findings: Sagittal plane angulation of greater than 11 degrees between adjacent segments, (NOT MET) and Subluxation or translation of greater than 3 mm on static lateral views or dynamic radiographs (NOT MET) Cervical radiculopathy when ALL of the following criteria are met: progressive neurologic deficits (with or without associated pain) OR unremitting severe radicular pain (MET) (with or without associated neurologic deficits), failure of at least 6 weeks of conservative therapy (NOT MET), imaging studies which demonstrate nerve root compression correlating with the distribution of signs and symptoms (NOT MET).
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 neck surgery (procedure codes 22551, 22552, 22853, 20937, 20930, and 20939) and related hospital admission is not substantiated.