Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two level artificial disc replacement.Findings:  Three physician reviewers found that the patient presented with neck pain radiating into the right upper extremity with weakness and numbness. On 4/13/16, cervical spine magnetic resonance imaging documented disc desiccation and narrowing at C5-6 with a 2-3 mm broad-based osteophyte lateral component along with uncovertebral joint hypertrophy contributing to severe right and moderate left foraminal stenosis. At C6-7, there was disc desiccation, a 2 mm bridging osteophyte and right uncovertebral joint hypertrophy with a more focal 2-3 mm right foraminal protrusion contributing to moderate to severe right C7 foraminal stenosis. There was moderate left foraminal stenosis and minimal central canal stenosis. The 5/2/16 treating physician report cited a two-month history of neck pain radiating to the right arm with right triceps weakness and numbness and tingling into the right hand. The patient noted that he was dropping objects, but had no difficulties with balance. He denied a history of trauma. He had tried oral steroids and an epidural injection. He had grade 8/10 pain with difficulty sleeping and sitting due to pain. A physical examination documented no antalgia or spasticity. Cervical range of motion was full and unrestricted, but he had pain with extension causing right arm symptoms. He had failed to achieve sustained improvement with physical therapy and epidural injections. He felt that he was losing strength in his arm. The patient requested authorization for two level artificial disc replacement.  The patient did not want to undergo cervical fusion.  Evidence based medical peer-reviewed literature supports the use of two level artificial disc replacement (ADR) as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease. On study performed a prospective, randomized, controlled multicenter clinical trial on two level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two level anterior cervical discectomy and fusion. This patient presented with neck pain radiating into the right arm with weakness and numbness. Functional difficulty was noted in activities of daily living and recreational pursuits. Clinical exam findings are consistent with imaging evidence of degenerative disc disease at the C5-6 and C6-7 levels with plausible neural compression. Recent conservative non-operative treatment has been tried and failed to provide sustained improvement. The use of two level artificial disc replacement will allow for motion preservation, which would be sacrificed with the use of fusion. Final Result: Three reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts 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.