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

An enrollee has requested authorization and coverage for lumbar fusion-multiple levels: decompression and fusion.Rao and colleagues have found that anterior lumbar interbody fusion (ALIF) is an effective treatment for degenerative disc disease (with and without radiculopathy) or spondylolisthesis. Further studies were recommended, however, to establish the effectiveness of ALIF for scoliosis, failed posterior fusion, and adjacent segment disease. Wang and colleagues have supported the 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. Orita and colleagues 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.In this case, the patient presents with complaints of constant severe low back pain radiating into the right lower extremity in a reported L4 distribution. While she has functional limitations noted in walking tolerance, her clinical exam findings are reported to be benign. There is imaging evidence of right sided disc herniation at L4/5 with abutment of the right L4 nerve root in the far lateral zone, and moderate right neuroforaminal stenosis. At L5/S1, there is imaging evidence of mild right and moderate left neuroforaminal narrowing. There is also radiographic evidence of moderate to severe L4/5 and L5/S1 degenerative disc disease. The procedure under consideration involves anterior lumbar interbody fusion at L5/S1 and posterior instrumented fusion at L4/5. However, the submitted documentation does not support that the requested procedure is medically necessary. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is also no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Furthermore, there are no clinical exam findings of neurologic deficit, and the submitted documentation does not set forth evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure. There is also no documentation of the patients response to the proposed right L4 selective nerve root block. Under these circumstances, the requested lumbar fusion-multiple levels: decompression and fusion is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of 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.