Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an artificial disc replacement (C6/C7 level). Findings:  The physician reviewer found that the patient who has a history of neck problems. The patient was status post total disc replacement at the C5/6 level. The patient presented for orthopedic evaluation for left sided neck and shoulder pain and left weakness. The patient had been treated with facet injections at the C6/7 and C7/T1  with exponentially increased pain. The patient underwent a left C5 epidural steroid injection  with some reduction of pain during the anesthesia phase. The patient reported a difficult time with grip but no difficulty with fine motor skills, no myelopathic gait, no associated falls, and no bowel/bladder incontinence. The patient is on several pain medications. A magnetic resonance imaging report documented significant artifact from the ProDisc at C5/6 that skews the adjacent discs. There was a left C6/7 herniated nucleus pulposus. The treatment plan recommended a cervical spine computed tomography (CT) scan to assess pathology adjacent to the C5/6 level. The  cervical spine x-ray report impression documented no significant interval change. There was an intact C5/6 disc arthroplasty without evidence of hardware failure or change in alignment and no evidence of spinal canal or foraminal stenosis. The patient reported severe pain running down her left arm that prevented her from doing many of her normal activities and made it difficult to sleep. The reported that the had been receiving steroid injections every six months for eight years. Thepatient spent six weeks in bed over the summer, unable to move her arm without excruciating pain. The  patient received an injection that helped for a while, but it was wearing off and the pain was rapidly returning. The patient requested coverage for an artificial disc replacement (C6/7 level). The Health Plan denied the requested services as investigational for treatment of this patient.  Evidence based medical peer reviewed literature and guidelines generally do not support single-level artificial disc replacement in the setting of multilevel cervical degenerative disc disease. There is some support for a two-level disc arthroplasty for symptomatic degenerative disc disease limited to two contiguous levels. This patient presents with cervical pain radiating into both shoulders, left greater than right. Functional difficulties affect activities of daily living. Her symptoms have failed to resolve with reasonable conservative treatment. Clinical examination findings document motor deficits generally consistent with imaging evidence of C6/7 and C7/T1 degenerative disc disease with neuroforaminal narrowing. There was imaging evidence of prior C5/6 artificial disc replacement without hardware complication and multilevel degenerative disc disease at the C4/5, C6/7 and C7/T1 levels. However, the medical literature provides no compelling rationale to support the superiority of C6/7 artificial disc replacement over standard anterior cervical discectomy and fusion for this patient in the setting of multilevel cervical degenerative disc disease. Therefore, the artificial disc replacement (C6/7 level) is not likely to be superior to the available standard modalities for treatment of the patients medical condition. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experst 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.