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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for multi-level lumbar fusion (revision L3-4, L4-5 laminectomy, and fusion TLIF with autograft, allograft bone, and neuromonitoring) (CPT 22634).Bydon and colleagues note, 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 agree and 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 describe, 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. However, there are medical concerns regarding spondylolisthesis that should be addressed before surgical treatment, including a determination of existing and/or inevitable temporary intraoperative instability. Therefore, treating provider documentation and/or inevitable/temporary intraoperative instability should be documented and standard documentation of guideline and/or literature-associated surgical indications. This is separate from exhaustion of prior non-operative treatments.In this case, there are no dynamic flexion/extension films to assess the amount of movement or instability. Additionally, there is no MRI or computed tomography that shows any potential inevitable temporary intraoperative instability. The disc bulge at L3-4 is 1 mm and L4-5 is 2 mm with mild loss of disc signal noted. The provided documentation does not fully support surgical pathology at the requested lumbar levels of L3-4 and L4-5. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, multi-level lumbar fusion (revision L3-4, L4-5 laminectomy, and fusion TLIF with autograft, allograft bone, and neuromonitoring) (CPT 22634) is not medically necessary for treatment of the patients medical condition.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.