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

Physician 1: The patient is a 44-year-old man with two level degenerative disc disease at L3-4 and L5-S1 resulting in severe back pain. He has tried and failed conservative treatments and is now requesting multi-level artificial disc replacement to resolve his back problems. The Health Plan has denied authorization for the procedure because it is considered investigational.To date, there is no long-term data supporting the benefits of artificial disc replacement over more conventional surgical interventions.  Additionally, there is a paucity of data on the outcome of multiple disc replacements in general, and more specifically when the disc replacements are at non-contiguous levels. These procedures in particular are currently considered experimental/investigational. Because there is insufficient evidence supporting the safety and efficacy of artificial disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 44-year-old male with degenerative disc disease at L3-4 and L5-S1. The patients provider indicates the patient has attempted available conservative therapies without sustained relief. Multi-level artificial disc replacement has been recommended. The Health Plan indicates the safety and efficacy of artificial disc replacement has not been established in peer-reviewed literature.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion, especially in cases such as this that involve a two level arthroplasty with an intervening level. The long-term safety profile of artificial disc replacement is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 44-year-old male with degenerative disc disease who has failed medications for pain and steroid injections. The patients physician has recommended he undergo artificial disc replacement at multiple levels. The Health Plan has denied authorization and coverage for the proposed procedure on the basis it is considered experimental.The Health Plans denial should be upheld. Although artificial disc replacement is a novel approach to the management of chronic discogenic low back pain, it has not been shown to be superior to interbody fusion. At this time, there is insufficient peer-reviewed evidence demonstrating the long-term safety and efficacy of the proposed procedure. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.