Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 51-year-old female with neck pain. The patient has requested authorization and 
coverage for insertion of a biomechanical device (PEEK cage). The physician reviewer found that 
anterior  cervical  discectomy  and  fusion  is  one  of  the  most  common  surgical  procedures 
performed by the spine surgeon. It is used to treat cervical stenosis causing radiculopathy, 
myelopathy, or both. The gold standard substance used to place in the disc space for arthrodesis 
is iliac crest autograft. Due to the morbidity associated with collected iliac crest bone graft, 
alternatives have been sought. Structural allograft and synthetic cages made of PEEK, titanium, 
or other substances have been used widely. There is a paucity of evidence supporting the efficacy 
of synthetic cages and their superiority over allograft. Moo and colleagues evaluated their 88 
patient cohort comparing three-year follow up results for two-level anterior cervical discectomy 
and fusion in whom allograft or synthetic cages were used.  Although similar clinical outcomes 
were achieved, subsidence rates were meaningfully higher in the synthetic cage group. Marrache 
and colleagues evaluated private claims data in 26,754 patients who underwent anterior cervical 
discectomy and fusion to study allograft versus synthetic cages (PEEK). There were no meaningful 
differences in complication rates acutely. During a two-year follow-up period, synthetic cages 
resulted  in  a  significantly  higher  all  cause  reoperation  rates  versus  allograft.  Menon  and 
colleagues retrospectively reviewed a national research database of over 6,500 patients who 
underwent anterior cervical discectomy and fusion with either allograft or synthetic cages.  For 
single level surgery, results were similar. However, revision surgery was significantly more 
frequent in multilevel surgery where synthetic cages were used. Teton and colleagues sought to 
evaluate pseudoarthrosis rates in their 81 patient series to compare allograft versus synthetic 
cages (PEEK). They identified significantly higher rates of symptomatic pseudoarthrosis rates in 
single level anterior cervical discectomy and fusion patients with synthetic cages. Buyuk and 
colleagues reviewed over 200 patients who underwent one and two-level anterior cervical 
discectomy and fusion using either structural allograft or synthetic cages (PEEK).  Although 
subsidence rates were similar, rates of symptomatic pseudoarthrosis were higher with synthetic 
cages, although not statistically significant. Ryu and colleagues reviewed prospectively collected 
data from 194 patients who underwent one up to three level anterior cervical discectomy and 
fusion surgeries to compare outcomes with structural allograft and synthetic cages (PEEK). In 
patients for whom synthetic cages were utilized, radiographic non-union rates were higher, and 
in patients with multilevel surgeries, the risk of non-union was 5.8 times higher than with 
structural  allograft.  Pirkle  and  colleagues  performed  a  retrospective  database  review  of  a 
national health plan database.  They evaluated over 6,130 patients operated upon to compare 
outcomes of structural allograft and synthetic cages used for anterior cervical discectomy and 
fusion surgery. Non-union rates were significantly higher in patients in whom cages were used, 
even when confounders were controlled (5.32% versus 1.97%). The authors concluded that 
allograft was likely superior to synthetic cages for anterior cervical discectomy and fusion. Based 
on the current medical evidence, the requested insertion of PEEK cage is not medically necessary 
in the treatment of this patient in order to perform a three-level anterior cervical discectomy and 
fusion. Therefore, the requested insertion of a biomechanical device (PEEK cage) is not medically 
necessary for the treatment of this patient.