Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kyphosis

Treatment: surgical procedures 22610 x (times) 1, 22614 x 9, 22612 x 1, 63046 x 1, 64047 x 1, and 63408 x 9 (spinal fusion)

The insurer denied coverage for surgical procedures 22610 x 1, 22614 x 9, 22612 x 1, 63046 x 1, 64047 x 1, and 63408 x 9, spinal fusion

The denial is upheld.

The patient has a history of chronic obstructive pulmonary disease (COPD), spine surgery, hypertension, and diabetes. 

A lumbar MRI (magnetic resonance image) noted a posterior fusion from lumbar (L)2 to L5. The L2 screws extend into the L1-2-disc space. There is formation of focal kyphosis at the L1-2 level. A computed tomography (CT) lumbar spine notes the right screw extends into the right L1-2-disc space. No acute fractures. Orthopedic surgery notes she is status post L2-L4 Transforaminal lumbar interbody fusion (TLIF)  with revision of hardware at L4-5 approximately few months ago. She continues with ongoing back pain with numbness and tingling to bilateral lower extremities status post fall and re-evaluation for possible surgical appeal. She had proximal junction kyphosis with failure of the bone fusion with screws going up through the disc at the superior level and she is going into kyphosis. She is treated with Fosamax, calcium and vitamin D. She is smoke free. She wears a thoracic-lumbo-sacral orthosis (TLSO) brace and using a walker. Her exam notes the inability to heel, or toe walk bilaterally. She has postural kyphosis and leans forward due to pain at the thoracolumbar junction. She has spasms and decreased lower extremity tone. Motor strength is 4/5 throughout. A lumbar x-ray states the right L2 screw extends into the disc space at L1-2, increase in height loss at L2 superior endplate, interval development of kyphosis at L1-2 and concerning for hardware failure. She has rapid worsening of pain in the lumbar and sacro iliac into the bilateral thighs, pain 9/10. The surgeon notes a pars defect at L1-2 above her fusion where the kyphosis occurs as well as the L2 height loss involving the L2 screw going through the endplate secondary to causing hardware failure secondary to osteopenia. Prior to her fall she was doing well. The plan was to proceed with T8-L5 instrumented fusion with possible S2 instrumented fusion secondary to osteopenia, ongoing back pain and kyphosis.

The imaging does not measure her kyphosis and does not meet policy criteria for kyphosis. 

The patient has failure of hardware at L2-3 due to a fall which is causing a new kyphosis at the level above her fusion. The screw is going through the disc space. The surgeon wants to extend the fusion to thoracic (T)8 and down to S (sacral)1-sacrum. It is not clear why the fusion needs to be extended to T8 when her kyphosis is at L1-2. Imaging does not measure her kyphosis and there is no indication of a pars defect or instability. She does not have a progressive neurological deficit or severe weakness that qualifies for immediate surgical intervention. Therefore, the request does not meet medical necessity. 

National Imaging Association (NIA) guidelines Lumbar Deformity (With Or Without Secondary Thoracic Involvement) In Adults:

Progressive neurological deficit (motor deficit, bowel or bladder dysfunction) or lower extremity weakness (0-3/5 on the strength scale) or paralysis with corresponding evidence of spinal cord or nerve root compression on an MRI [magnetic resonance imaging] or CT scan images -immediate surgical evaluation is indicated (Kreiner, 2014); OR

When ALL of the following criteria are met:

1)	Lumbar back pain, neurogenic claudication, and/or radicular leg pain without significant motor deficit (0-3/5) that impairs daily activities for at least 6 months; AND

2)	Failure of symptom or pain improvement upon completion of at least 12 weeks of focused non operative therapy/rehabilitation* in the past year AND

3)	Imaging studies that correspond to clinical findings and show at least one of the following

4)	Sagittal or coronal imbalance of at least 5 cm measured on long plate standing x-rays of the entire spine; OR

5)	Documented progression of 10 degrees in one year in the coronal plane on x-ray (scoliosis); OR

6)	A fixed scoliosis of at least 40 degrees. (1)

NIA guidelines Revision surgery for failed previous operation(s) for pseudoarthrosis at the same level at least 6-12 months from prior surgery** if significant functional gains are anticipated.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for surgical procedures 22610 x 1, 22614 x 9, 22612 x 1, 63046 x 1, 64047 x 1, and 63408 x 9, spinal fusion is upheld Medical Necessity is not substantiated.