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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cervical spine surgery (artificial disc replacement at C4-5 and C5-6 and foraminotomy with anterior cervical discectomy and fusion (ACDF) at C7-T1). Findings:  The physician reviewer found that Boddapati and colleagues have noted that many patients with multilevel disease are not good candidates for cervical disc arthroplasty (CDA) at all levels. For such patients, hybrid surgery, a combination of adjacent anterior cervical discectomy and fusion (ACDF) and CDA, may be more appropriate. They concluded that patients undergoing hybrid surgery are not at increased risk of perioperative complications relative to a 2-level ACDF and may benefit from shorter length of stay. Visocchi and colleagues retrospectively reviewed clinical, surgical, and outcome data and concluded that although the optimal surgical technique for cervical degenerative disc disease remains controversial, hybrid surgery represents a safe and effective procedure in selected patients with multilevel cervical degenerative disc disease.In this case, the patient had a history of anterior cervical discectomy and fusion (ACDF) at C6-7, and he had been diagnosed with cervical myelopathy and C8 radiculopathy. Imaging showed severe central stenosis at C4-5, C5-6 and C7-T1 with foraminal stenosis at C7-T1 where there was a grade 2 spondylolisthesis. Under these circumstances, surgical intervention was warranted, as there was no role for nonsurgical treatment for progressive cervical spondylotic myelopathy.There is much literature regarding surgical approaches to treat cervical spondylotic myelopathy, but both anterior and posterior approaches are reasonable. Essentially, it is up to the surgeon to decide what approach is best in their hands for the patient. In this case, the patients surgeon indicated that a posterior approach would require extensive multilevel fusion. Under these circumstances, an anterior approach was reasonable, as was ACDF at the C7-T1 level, given the presence of spondylolisthesis. Cervical disc replacement is approved for 1 or 2 level surgery between C3 and C7, for cervical radiculopathy or myleopathy. Cervical disc replacement next to a previous fusion or at the same time as a new fusion (so called `hybrid` surgery) has been shown to be a safe and effective option. The disc replacement at issue can be expected to decrease the rate of future degeneration of the patients remaining discs at C3-4 and C2-3. Accordingly, the cervical spine surgery (artificial disc replacement at C4-5 and C5-6 and foraminotomy with anterior cervical discectomy and fusion (ACDF) at C7-T1) at issue was medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.