Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain 

Treatment: back surgery (22842 x 1)

The insurer denied coverage for back surgery (22842 x 1)

The denial is overturned

According to the documents reviewed, this patient reports debilitating low back and leg pain and inability to walk more than short distances. She has failed multimodal conservative treatment including physical therapy and epidural steroid injection (ESI). She had previous lumbar laminectomy. Her physical exam is significant for no focal motor or sensory deficit and normal reflexes. 

The magnetic resonance imaging (MRI) of her spine shows a grade 1 spondylolisthesis at lumbar (L) 4-5 with bilateral pars defects and severe bilateral stenosis with bilateral L4 nerve root compression. She was offered a L4-L5 front and back instrumented fusion with interbody cage. Given that this is a form of spinal instability, and that the pain has not improved with conservative treatment, the proposed surgery should have been approved in the patient's best interest. Thus, the 22842 code, posterior lumbar instrumentation, meets medical necessity, given that the patient requires stabilization at L4-5.

"Degenerative spondylolisthesis (DS) is an acquired anterior vertebral displacement without a disruption of the pars interarticularis, associated with the degenerative changes of aging, such as intervertebral disc degeneration, ligamentous hypertrophy or buckling, and osteophyte proliferation [1, 2]. Treatment of DS has long been a topic of debate, as multiple modalities are currently utilized. For example, in a recent analysis, 95,647 Medicare patients with a diagnosis of lumbar DS, 40% were treated with corticosteroid injections, 37% were treated with physical therapy, and only 22% were treated surgically [3]. When considering surgical treatment variations with data from the Spine Patient Outcomes Research Trial (SPORT), 7% were treated with decompression alone, 21% were treated with non-instrumented fusion, and 71% were treated with fusion surgery [4]. The reoperation rate is also high at 22% at 8 years after initial surgery. Nevertheless, surgical treatment of DS with symptomatic spinal stenosis has been shown to be cost-effective with gain of 0.43 quality adjusted life years (QALYs), or greater for patients with multilevel disease [4]." (Samuel et al., 2017)

"Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population. 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." (Chan et al., 2019)

"Degenerative lumbar spondylolisthesis is one of the most common causes of low back pain and is defined as displacement of one vertebra over subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring. Understanding natural history of degenerative spondylolisthesis is important to tailor an individualized management plan for each patient. 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." (Bydon et al., 2019)                                                       

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for back surgery (22842 x 1) is substantiated.