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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for decompression and fusion surgery at the L4-L5 and L5-S1 level.Studies concluded that surgery should be considered when the lumbar foraminal stenosis pathology is refractory to conservative treatment and requires direct decompression of the exiting nerve root, including the dorsal root ganglia. In cases with decreased intervertebral height and/or instability, fusion surgery should also be considered. Studies support consideration of lumbar fusion for patients with degenerative disc disease and disc herniations with radiculopathy based on low level evidence when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor.In this case, the patient has a history of chronic low back pain with complaints of paralysis/numbness in the legs and lower half of his body. He is reportedly unable to walk and has been using a wheelchair. Clinical exam findings have documented 0/5 bilateral lower extremity strength, decreased sensation from the waist down, and inability to stand without assistance. There is imaging evidence of degenerative disc disease at L4/5 and L5/S1, including an L5/S1 disc protrusion with mild to moderate lateral recess narrowing contacting the traversing left S1 nerve root. A full spine MRI has been obtained, and spinal cord compression has been ruled-out. A recent electrodiagnostic study showed no evidence of lumbar radiculopathy. He has failed to improve despite long-term conservative treatment.  The patient has been evaluated by three spine surgeons. The most recent opinion indicated that the patient should be considered for surgery if there is electrodiagnostic evidence of radiculopathy. A request for decompression and fusion surgery at the L4/5 and L5/S1 levels is under consideration at this time. Current evidence based medical literature does not support surgery at this time, however. Clinical findings do not evidence a focal neurologic deficit correlated with imaging findings at the L4/5 and/or L5/S1 level. There is no electrodiagnostic evidence of radiculopathy. There is no imaging evidence of severe degenerative disc disease at either L4/5 or L5/S1, or clear evidence of nerve root compression consistent with the reported signs/symptoms. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays to support a lumbar fusion. It does not appear that the tertiary center spinal surgeon has reviewed the recent electrodiagnostic studies to confirm his surgical recommendation. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request at this time. Therefore, the requested decompression and fusion surgery at the L4/5 and L5/S1 level is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic 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.