Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other cervical disc displacement at C (cervical) 5-6

Treatment: Total Disc Arthroplasty and all associated charges listed on the facility claims (Outpatient surgical and facility services)

The insurer denied coverage for Total Disc Arthroplasty and all associated charges listed on the facility claims (Outpatient surgical and facility services).

The denial is upheld.

This case involves an adult female with a medical history of mixed hyperlipidemia, prediabetes, major depressive disorder, and other specified anxiety disorder. The patient was diagnosed with other cervical disc displacement at C (cervical) 5-6. The patient was seen for an evaluation. She had a history of progressively worsening left ear pressure/pain and dizziness symptoms. She reported some pain over the left mastoid. She denied neck pain and radiating symptoms into the extremities. She reported some balance trouble. The exam findings of the patient noted that her neck was normal to palpation. There was no tenderness of the spine. She had 5 out of 5 strength in the bilateral upper extremities. Her deep tendon reflexes were normal and symmetrical. Her sensation was intact to light touch. A magnetic resonance imaging (MRI) scan of the cervical spine was reviewed. The patient had a fairly large right-sided disc herniation at C5-6 that indented the cord. This resulted in severe central foraminal stenosis on the right. The provider stated that they did not believe that this was likely responsible for her left-sided ear, scalp, and occipital pain. The provider recommended a C5-6 anterior cervical discectomy and fusion versus arthroplasty to decompress the spinal cord and reduce the patient's risk of spinal cord injury. She was admitted to the hospital with cervical stenosis. She was brought to the operating room and underwent a C5-6 arthroplasty which was performed without complications. Postoperative images showed excellent correction. The patient worked successfully with physical therapy. She was discharged home with outpatient neurological surgery follow-up. 

Per the referenced guidelines, total disc arthroplasty may be an alternative to anterior cervical discectomy and fusion for intractable symptomatic 1 level or 2 level cervical degenerative disc disease with radiculopathy and/or myelopathy. The documentation should identify failure of nonoperative treatment. In this case, it was reported that the patient had a large right-sided disc herniation at C5-6 that indented the cord. This resulted in severe central foraminal stenosis on the right. It was noted that she had received some treatments for left ear pressure/pain and dizziness symptoms. It was argued that the total disc arthroplasty was substantiated by the clinical documentation. The patient had a history of progressively worsening left ear pressure and pain. The patient was noted to have a right-sided disc herniation. However, the documentation did not identify that the patient had symptoms consistent with radiculopathy and/or myelopathy. The patient's exam findings noted intact strength, intact sensation, and no reports of radiating symptoms. The documentation did not identify that the patient had failed any conservative care directed towards the cervical spine. The documentation did not report on flexion and extension x-rays of the cervical spine to confirm a lack of cervical instability at the requested level. The patient had left-sided complaints, but her herniation was right-sided. 

Proceeding with surgical intervention in an asymptomatic patient is not recommended. Thus, the medical necessity of the treatment has not been established. As such, the denial of total disc arthroplasty and all associated charges and the related anesthesia, radiology, and assistant surgeon services was appropriate and is upheld.

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The total disc arthroplasty and all associated charges and the related anesthesia, radiology, and assistant surgeon services were not medically necessary for the patient.

The insurer's denial of coverage for the Total Disc Arthroplasty and all associated charges listed on the facility claims (Outpatient surgical and facility services0; and the related anesthesia, radiology, and assistant surgeon services (procedure codes 00600-QX1-P2, 00600-QK-P2, 72040-26, 7240-26-76, and 22856-AS) provided by physician, is upheld. Medical necessity is not substantiated.