Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery to remove and replace hardware on an inpatient basis for treatment of the enrollees low back and right buttock, leg and groin pain. Findings:  The physician reviewer found that in a comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified. Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc; 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. The American Pain Society (APS) has also developed evidence-based recommendations on the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain (Chou, et al). A multidisciplinary panel reviewed 3348 abstracts and a total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations and noted that, In patients with persistent and disabling radiculopathy due to herniated lumbar disc or persistent and disabling leg pain due to spinal stenosis, it is recommended that clinicians discuss risks and benefits of surgery as an option (strong recommendation, high-quality evidence). Specifically, the authors state For persistent and disabling radiculopathy due to herniated lumbar disc, standard open discectomy and microdiscectomy are associated with moderate short-term (through 6 to 12 weeks) benefits compared to nonsurgical therapy. However, the authors concluded that the differences in outcomes in some trials are diminished or no longer present after 1 to 2 years. Overall, fusion is not recommended for such patients. Based on these two comprehensive literature reviews, surgical fusion at the L3-4 level, removal of hardware at L4-5, and laminotomy and decompression on the right at L5-S1 are not medically necessary for management of this patients medical condition.