Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis

Treatment: Lumbar fusion (arthrodesis)

The insurer denied coverage for lumbar fusion (arthrodesis).

The denial is overturned.

The patient has a history of L (lumbar) 4-L5 arthrodesis. He presented to the Family Medicine practitioner's for a preoperative evaluation. A lateral interbody fusion at L2-3 and L3-4 and noted disk degeneration and stenosis and possible L2-3 osteomyelitis as diagnoses. He noted that prior to surgery the claimant had accelerated progression of degeneration at L2-3 "with concerns for potential osteomyelitis," and also the patient had back pain and left leg pain.

Nurse practitioner noted the patient has back and leg pain. He was noted to have palpable midline tenderness in the low back and pain with ambulation. He was noted to have muscle spasms to the lumbar spine "causing significant discomfort." His body mass index (BMI) was 33 and he was noted to be a nonsmoker. "Due to continual symptoms" that had not improved after "conservative therapy," she determined that the claimant was cleared for surgery.

The doctor noted the patient had prior L4-5 fusion and has back pain and left leg pain. Also had a knee infection one year ago and has since had rapid progression of L2-3 spinal segment. He is deteriorating significantly, and his left leg is numb and feels weak. He has a history of spinal cord stimulator and prior cervical and lumbar fusions, and right ulnar nerve surgery. He was in moderate discomfort and was having visible spasms. He has antalgic gait and limited range of motion (ROM) of the spine. There is numbness in a left L4 distribution and "some left lower extremity weakness also" was noted. The magnetic resonance imaging (MRI) showed rapid degeneration at L2-3 with signal changes in the disk space and vertebral bodies of L2 and L3 possibly consistent with osteomyelitis. Moderate to severe stenosis at L2-3 was noted, and degenerative findings at L3-4 were also reported.

According to Yavin, D., et al (2017), "The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality."

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.      

The lumbar fusion (arthrodesis) performed is considered medically necessary for this patient.

The records confirm the patient had chronic pain and had been engaged in nonsurgical care for some time. The presence of spondylolisthesis and severe stenosis at L2-3, with disk space and vertebral body reactive changes possibly consistent with osteomyelitis, all confirm that the surgery was medically necessary and that without the surgery the patient was at risk for further extension of the infection, further pain and suffering, and further loss of neurologic function.

The records show the patient had severe pain and weakness in the left leg. Furthermore, radiographic images confirmed significant progression of disk space degeneration at L2-3, possibly consistent with osteomyelitis. The patient was noted to have a history of infected knee arthroplasty within the past year. Magnetic Resonance Imaging (MRI) lumbar confirmed severe stenosis at L2-3 and the claimant was suffering from painful muscle spasms and had visible difficulty walking. Therefore, the surgery was medically necessary because the patient was suffering and in pain and had loss of neurologic function with left leg weakness and inability to walk well and was at risk for uncontrolled extension of possible spinal infection without debridement.

The insurer's denial of coverage for lumbar fusion (arthrodesis) is overturned. Medical necessity is substantiated.