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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal surgery (CPT codes: 22551  arthrodesis, anterior interbody, including disc space preparation; 22552  arthrodesis, anterior interbody, including disc space preparation; 22846  anterior instrumentation, 4-7 vertebral disc segments; 20930  allograft for spine surgery only, morselized; and 20936  autograft for spine surgery only, includes harvesting). Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the requested surgery in this clinical setting. The medical literature recommends anterior cervical fusion as an option with anterior cervical decompression if clinical indications are met. Surgical indications for decompression include evidence of radicular pain and sensory symptoms in a cervical distribution that correlate with the involved cervical level or a positive Spurlings test, evidence of motor deficit or reflex changes or positive electromyography findings that correlate with the involved cervical level, abnormal imaging correlated with clinical findings, and evidence that the patient has received and failed at least a six to eight week trial of conservative care. Cervical fusion is recommended for spondylotic myelopathy based on clinical signs and/or symptoms and diagnostic imaging demonstrating spinal cord compression. Studies concluded that cervical radiculopathy will likely improve with surgery or non-operative care and recommended structured physical therapy before surgery is chosen. Studies concluded that surgical decompression for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality-of-life outcomes regardless of severity of the pre-operative symptoms. This patient presents with a history of progressively worsening neck pain and headaches with numbness and tingling in both hands and pain radiating down the right upper extremity. Functional difficulty was reported in activities of daily living and work ability. Clinical examination findings were consistent with myelopathy and imaging evidence of severe right sided foraminal stenosis involving the entire foramen at C4/5 with a large disc osteophyte complex, severe right sided foraminal stenosis at C5/6, and moderate to severe central and left-sided foraminal stenosis at C6/7. Detailed evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure have been submitted. Evidence based medical guidelines and peer-reviewed literature indications have been met to proceed with the requested surgery. Therefore, the requested spinal surgery (CPT codes: 22551  arthrodesis, anterior interbody, including disc space preparation; 22552  arthrodesis, anterior interbody, including disc space preparation; 22846  anterior instrumentation, 4-7 vertebral disc segments; 20930  allograft for spine surgery only, morselized; and 20936  autograft for spine surgery only, includes harvesting) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.