Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Inpatient Spine Surgery (22830 x (times) 1, 22850 x 1, 64722 x 1)
The insurer denied coverage for Inpatient Spine Surgery (22830 x 1, 22850 x 1, 64722 x 1).
The denial is upheld.

The insurer has denied coverage for Inpatient Spine Surgery (22830 x 1, 22850 x 1, 64722 x 1). In their Final Adverse Determination letter, they write that the patient has back pain. The patient asked for a surgery on the spine. The patient has had surgery on the back before, a procedure called Spinal Fusion. To approve this service, the following criteria must be met: 
Criteria from the Turning Point guideline named "Lumbar Spinal Fusion" OR-1004. Also the guideline named "Medical Record Documentation" GN-1002. Based on the information provided, these criteria are not met because: the patient's records do not show improper fusion of the bones after the prior surgery, due to a failure of instruments or equipment.

The provider is appealing. In an appeal letter, it stated that this is a continuation of care. The provider performed a previous lumber spine surgery. The patient only trusts this provider to remove the hardware from the previous surgery. It is the best medical treatment to be under the care of this provider, and the patient doesn't need or want their health to deteriorate.

According to the medical records, the patient previously underwent Microdiscectomy of L (lumbar) 5-S (sacral) 1. A subsequent motor vehicle accident (MVA) necessitated the performance of a Lumbar Fusion which was planned for L5-S1 level but by report, the fusion was performed at the L4-5 level. The fusion is solid with no evidence of pseudoarthrosis. Computerized tomography (CT) scan is referenced as showing excessive bone formation that is causing neural foraminal stenosis. However, the report of the CT (Computerized tomography) is not provided. The Magnetic resonance imaging (MRI) scan does not show any neural foraminal compression.

There is no evidence presented that would meet criteria for the performance of wound exploration and removal of non-segmental instrumentation. There is no evidence of pseudoarthrosis or non-union. There is no evidence of instability. There is likewise no objective evidence of neural compression necessitating re-exploration and revision laminoforaminotomies.      

"Spinal fusion surgery is performed all over the world to help patients with cervical and thoracolumbar pathology. As outcomes continue to improve in patients with spine-related pathology, it is important to understand how we got to modern-day spinal fusion surgery. Scientific innovations have ranged from the first spinal fusions performed with basic instrumentation in the late nineteenth century to contemporary tools such as pedicle screws, bone grafts, and interbody devices" (3).

"Surgery may be done for fractures, dislocations, tumors, scoliosis, or other mechanical defects. Care must be taken regarding a patient's age, weight, and medical comorbidities. Complications may include neurological damage, incomplete relief of pain, vertebral fracture, and infection" (2).

"Peripheral nerve injuries are frequently encountered in clinical practice and often result in functional disability. In the past, due to poor understanding of pathophysiology, the results of nerve repair were unpredictable. Sunderland1 described the microsurgical techniques which improved the results of nerve repairs. In the past few decades an understanding of nerve regeneration, advances in microsurgical techniques, along with ongoing research in molecular biology has helped in improving the results in peripheral nerve surgery" (1).                                                         

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 Inpatient Spine Surgery (22830 x 1, 22850 x 1, 64722 x 1) is not substantiated.