Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Lower Back Pain

Treatment: the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L [lumbar] 5-S [sacral] 1) and one inpatient bed day

The insurer denied coverage for the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day

The denial is upheld

According to the medical records, the patient is an adult male who was seen and evaluated complaining of low back pain for years. The pain radiated to both gluteals. There was no tingling or weakness in the lower extremities. He has had physical therapy, multiple epidural steroid injections and radiofrequency ablation with minimal relief. He works as a lighting designer. A prior surgeon had recommended a lumbar fusion. On examination he was in no acute distress. He was alert and oriented. With range of motion, he complained of pain in his low back. The x-rays showed disc space narrowing at L5-S1 with no instability. Magnetic resonance imaging (MRI) study of the lumbar spine showed contact of both S1 nerve roots with a disc extrusion. it was recommended that he undergone disc replacement at L5-S1. An MRI of the lumbar spine showed disc desiccation a small disc bulge at L5-S1, there was no significant mass effect on the nerve roots. There was mild bilateral facet arthropathy at L5-S1. This request had previously been denied.

"Back pain is one of the most common causes for patients to seek emergency care. It has a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly, it is mechanical or non-specific. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. It is essential to be able to evaluate patients of all ages and recognize the unique differences in the presentation in these different populations. Knowing the typical red flags of back pain in both children and adults can guide the provider to appropriate evaluation and treatment." (Casiano, et al.)

"We assessed the recommendation grade for the primary treatment of acute and chronic low back pain (LBP). A variety of recommendation grades were determined for general behavior, pharmacological therapy, psychological therapy, and specific exercises. This analysis should be helpful to physicians in the treatment of LBP." (Hong, ET AL., 2017)

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to be anticipated in this patient. With the presence of facet arthropathy and no instability as well as the absence of neurological deficit, this patient is not a good candidate for a total disc arthroplasty.     

The total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) is not the best available treatment for this patient at this time. With the presence of facet arthropathy and no instability as well as the absence of neurological deficit, this patient is not a good candidate for a total disc arthroplasty. 

The standard treatment/procedures for this patient are likely to be more beneficial than the requested procedure. Adverse risks with this procedure are increased over standard treatment/services.                                                    

The carrier's denial of the total disc arthroplasty described by code 22857 at lumbar bone five to sacral bone one (L5-S1) and one inpatient bed day should be upheld.