Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Myelopathy.
Treatment total disc arthroscopy (artificial disc) affecting the neck area.
The insurer denied coverage for total disc arthroscopy (artificial disc) affecting the neck area.
The denial is upheld.

This is the case of a female patient with a 10-year history of progressive chronic neck pain, Charcot-Marie-Tooth disease, Ehlers-Danlos syndrome type III, Raynaud's disease and migraine. Internal Medicine notes that she had progressive neck pain with bilateral arm numbness and tingling with intermittent facial numbness and bilateral arm weakness. She had headaches and migraines. Symptoms aggravated with exercise or lifting her arms overhead. She had some relief with rest and ibuprofen. She was not a smoker. She was cleared for surgery.

A History and Physical by Neurosurgery stated the patient had cervical myelopathy and Ehlers-Danlos syndrome and bilateral arm symptoms.

A surgical discharge summary stated that she was admitted. Her diagnoses listed cervical spondylosis with radiculopathy, cervicalgia and herniated disc with myelopathy cervical. Her hospital course stated that she had been experiencing neck pain with associated upper extremity symptoms. Conservative management had failed to resolve the symptoms and therefore, surgical intervention was decided. She underwent arthroplasty, anterior approach with discectomy C (cervical) 6-7 with Prestige by Medtronic. The operative report findings stated that she had severe compression from osteophytes, herniated disc that indented the spinal cord centrally. The indication was for cervical myelopathy.

Derrick G. Sueki, et al reports that anterior cervical discectomy is indicated for: Progressive cervical myelopathy; Radiculopathy that has failed to respond to conservative treatment regimen of at least 6 weeks; Recurrent radiculopathy; Progressive neurologic deficit; Severe, incapacitating axial neck pain that fails to respond to prolonged course of conservative treatment with consistent examination and diagnostic studies confirming cervical disc disease. (1)

According to the National Committee for Quality Assurance (NCQA), consistent, current, and complete documentation in the medical record is an essential component of quality patient care. Some commonly accepted standards for medical record documentation, per the NCQA, include the following and the medical records reviewed fail to meet: g. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient's presenting complaints; h. Working diagnoses are consistent with findings; i. Treatment plans are consistent with diagnoses. (3)

The documentation failed to provide preoperative office notes with exams and preoperative imaging. Thus, preoperative records are not provided to support the need for artificial disc replacement. 

The total disc arthropathy was not medically necessary for the patient. Submitted medical records fail to include Neurosurgery notes prior to surgery that would include exams and fails to include a cervical magnetic resonance imaging (MRI) and x-ray for review. It is unknown if the patient had cervical myelopathy and cervical radiculopathy due to herniated disc causing cord compression. Therefore, the surgery performed does not meet standard of care as it is unknown if the surgery was safe and effective for the patient's condition. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for the total disc arthroscopy (artificial disc) affecting the neck area is upheld. Medical necessity is not substantiated.