Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for multilevel lumbar fusion surgery. Bydon and colleagues state, A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Chan and colleagues state, Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. Resnick and colleagues state, As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this case, the patient is being treated for radiculopathy of the lumbar region. The patient reported that pain in the right leg was severe and made it difficult to complete activities of daily living. On examination, the patients strength and sensation were intact, with reflexes of 1+ in the patella and joints. There was severe pain right greater than left low lumbar facets and right greater than left facet joints. The patient was status post XLIF and posterior spinal fusion L3-4. X-rays did not document instability and MRI of the lumbar spine showed at L4-5 a disc bulge, mild bilateral facet arthropathy, prominent dorsal epidural fat, mild spinal canal stenosis and mild bilateral neural foraminal narrowing, on the right greater than left. The MRI showed at L5-S1  mild bilateral facet arthropathy, no spinal canal stenosis or neural foraminal narrowing, and right extraforaminal bony narrowing at the site of pseudoarticulation. While there appears to be a discrepancy between the interpretations of the radiologist and the treating provider regarding the findings on  the MRI, in this case, the pathology present on the imaging study does not appear to support the necessity of a large decompression that would potentially lead to intraoperative instability of the lumbar spine. Therefore, multilevel lumbar fusion surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert 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.