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

The patient is a 50-year-old female who was involved in a bus accident in 1999.  She underwent a C6-7 anterior cervical discectomy and fusion in February 2004. Post-operatively she apparently developed significant low back pain with radiation into the left posterior thigh and numbness and tingling in the plantar foot and pain radiating to the bilateral anterior thighs. An MRI of the lumbar spine performed in March 2004 showed minimal disc disease at L4-5 causing mild left neural foramen stenosis, which was unchanged. The patient was seen for a neurology consult in March 2004 for chronic upper and low back pain with mild facial pain. Reflexes were physiologic and her gait was normal. X-rays of the thoracic and lumbar spines in April 2004 showed minimal changes of degeneration through the inferior thoracic and lumbar spine and degenerative changes at a pseudoarthrosis between the right L5 transverse process and sacrum.  A pseudoarthrosis of L5 on the sacrum versus sacroiliac joint syndrome was diagnosed. A local anesthetic was injected into the joint. EMG/NCV studies of May 2004 were normal. In August 2004 the patient underwent a right pseudoarthrosis injection at L5-S1.  X-rays of the lumbar spine in September 2004 showed mild disc degenerative change at L5-S1 and anomalous articulation of the right L5 transverse process with the sacral ala. A right-sided pseudoarthrosis injection afforded no benefit and the patient continued with right-sided back pain and in October 2004 was given a lumbar epidural steroid injection.  An MRI of the lumbar spine without contrast in April 2005 showed no significant change in the left lateral recess stenosis at L4-5. The patient received another lumbar epidural steroid injection in June 2005.  The patient was evaluated on August 2005 for continued low back pain with bilateral proximal thigh radiation and left leg radiation. The patients provider indicated that the last of the two steroid injections resulted in improvement of lower extremity symptoms. The patient continued conservative treatment including injections, acupuncture, Pilates, tai chi, medications, yoga, a home exercise program, lumbar stabilization, transforaminal epidural injection at L5 and left L5 selective nerve root block and transforaminal L4 root injection.  She was evaluated again in November 2005 for more low back pain than leg pain with pain into the right groin and down in the right lumbosacral region, burning pain in the upper back and more frequent urination. She stated she was diagnosed with an L4-5 impingement in April 2005 but had some incontinence prior to that time and that she had an L5-S1 congenital problem, which was seldom symptomatic in the past, but that the motor vehicle accident caused an injury to that area. Chronic low back pain was diagnosed.  An MRI of the lumbar spine performed in January 2006 showed early degenerative disc disease of L2-3 and L4-5; a 2mm right intra-foraminal disc protrusion at L4-5 without neuro impingement, and an annular tear, which was stable since the last exam of April 2005.  The patient was evaluated in January 2006 for severe low back pain radiating into both legs, greater on the left.  It was noted that another orthopedic surgeon had recommended an intradiscal electrothermal annuloplasty (IDET), but that a pain management specialist disagreed and instead performed various injections. The exam was normal. The evaluator felt that the IDET was a reasonable treatment option. The patient continued treating with pain management and treatment for depression was recommended as well as continuation of a home exercise program.  A neurosurgeon evaluated the patient in July 2006. He did not believe that the patient would significantly benefit from a lumbar spinal fusion.  The patient is seeking authorization for discectomy and/or fusion at L4-5. The Health Plan has denied this request on the basis that the requested surgery is not medically necessary.Review of the submitted clinical evidence reveals a diagnosis of lumbar degenerative disc disease at L4-5 with possible posterior tear of the annulus fibrosis, minimal narrowing of the L4-5 lateral recess and L5 radiculitis, left side.  The proposed discectomy and/or fusion at this level are not medically necessary. The medical records provided including MRIs and attempted conservative measures as well as second opinion evaluations do not support the need for surgery in this clinical scenario. There is no evidence the patient would benefit medically from the requested surgery. Surgical intervention is not recommended for this patients chronic back pain from lumbar degenerative disc disease.Accordingly, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.