Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Discogenic low back pain, L5-S1.  

Treatment: Lower spine disc replacement with an artificial disc

The insurer denied coverage for lower spine disc replacement with an artificial disc. The denial was upheld.

This patient is a male currently diagnosed with discogenic low back pain, L5-S1. The lumbar MRI revealed at L5-S1 there was severe degenerative disc disease with marked disc height loss and diffuse disc bulging/osteophyte measuring up to 4 mm at the neural foramen, left side greater. The central canal remained patent. There was mild bilateral recess stenosis. There was severe left and moderate right foraminal stenosis. An office visit dated mid 2019 indicated the patient had a 2 year history of progressive low back pain radiating down the bilateral legs with associated symptoms of numbness and tingling into the right leg, the right calf, and the right foot.  Over the past several years, the patient had been doing physical modalities on his own, as well as supervised therapy with a chiropractor. The patient had seen pain management physicians and took anti-inflammatories, but his pain was still rated 9/10. The patient had 30% back pain, and 70% radiating pain. 

According to the North American Spine Society (NASS), Lumbar Artificial Disc Replacement is indicated for patients with discogenic low back pain who meet ALL of the following criteria from the Lumbar Fusion Coverage Recommendation:

1) 	Symptomatic single level lumbar disc disease at L3-L4, L4-L5 or L5-S1 level
2)  	Presence of symptoms for at least 6 months or greater and that are not responsive to multi-modal nonoperative treatment over that period that should include a physical therapy/rehabilitation program but may also include (but not limited to) pain management, injections, cognitive behavior therapy, and active exercise programs
3)  	Any underlying psychiatric disorder, such as depression, should be diagnosed and the management optimized prior to surgical intervention
4)  	Primary complaint of axial pain, with a possible secondary complaint of lower extremity pain		
Lumbar Disc Arthroplasty is NOT indicated in ANY of the following scenarios:

1) 	Any case that does not fulfill ALL of the above criteria
2) 	Presence of symptomatic degenerative disk disease at more than one level
3) 	Presence of spinal instability with spondylolisthesis greater than Grade I
4) 	Chronic radiculopathy (unremitting pain with predominance of leg pain symptoms greater than back pain symptoms extending over a period of at least one year)
5) 	Osteopenia as evidenced by a DEXA bone mineral density T-score less than or equal 
      to -1.0
6)  Poorly managed psychiatric disorder
7)  Significant facet arthropathy at the index level
8)  Age greater than 60 years or less than

There is no documentation that a trial of medial branch blocks, or lumbar epidural steroid injections, in order to define the pain generator, along with upright
x-rays and flexion extension dynamic x-rays to exclude the possibility of instability or spondylolisthesis. 

The health care plan acted reasonably and with sound judgment and in the best interest of the patient when denying the coverage for total disc replacement. The current documentation does not support the need for disc replacement surgery at this time.

The carrier's denial of continuation of coverage for lower spine disc replacement with an artificial disc is upheld. The medical necessity is not substantiated.