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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for spinal surgery and three days inpatient hospital stay. The enrollee has diagnoses of lumbar radiculopathy and thoracic progressive myelopathy. He reports a four-year history of back pain with symptoms that are constant, with radiation to his lower extremities, left greater than right.  His pain level is 6/10 and is worse with ambulating and bending, and improved with applying heat. He reports frequent falls, bladder and bowel incontinence, and an inability to maintain balance when ambulating.  His provider instructed him to lose weight. He began physical therapy (PT) and indicated it was causing a worsening of his symptoms and requested discharge from PT services. He has used narcotics for pain without relief.  While thoracic spinal stenosis (TSS) is much less common than in the cervical and lumbar spine, literature supports early decompression surgery for patients with TSS who develop myelopathy. This is because the caliber of the spinal cord has a tenuous blood supply, and severe neurological symptoms may develop if compression occurs and decompressive surgery is not performed promptly.  A series of patients with thoracic disc herniation indicated that over 80% reported improvement in pain score with an average follow-up of 14 months. Overall, there was also an improvement in Nurick grade function, which assesses ambulatory status. Importantly, there was no deterioration in neurological status. This supports the role of surgery in selected patients with thoracic herniations. A study regarding the outcome in patients with thoracic spinal stenosis and myelopathy who had spinal surgery found an improvement in Frankel scores, a scale of spinal cord injury, and JOA score, which assesses neurologic function for thoracic myelopathy. The literature supports spinal surgery for patients who have objective evidence of radiculopathy, such as significant weakness, myelopathy, or neurological deficits. Imaging should support significant spinal pathology, correlative with exam findings.  Significant instability is defined as a greater than 3mm spondylolisthesis, or a greater than 3mm shift on lateral flexion/extension films. The record indicates the enrollee had continued complaints of back pain, falls and decreased sensation to the lower extremities.  An MRI of the thoracic spine showed cord compression at T2-3, T4-5, T5-6 with disc herniation and T7-8.  Given symptoms of weakness in his legs, the surgery and three days inpatient stay are clearly indicated. Myelopathy for thoracic stenosis requires decompression and conservative routes are not effective in such cases given the possibility of permanent neurological deficits.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurosurgery 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 similar medical condition.