Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal fusion for the enrollee. 
 
You asked the Plan to pre-approve spinal fusion for the enrollee. You say that this surgery is medically 
necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage for this type of surgery. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pre-approve spinal fusion for the enrollee. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare Local Coverage Determination (L33382) for spinal fusion surgery states that lumbar 
fusion may be considered medically necessary and covered for the following indications: lumbar spinal 
instability, spinal stenosis, spondylolisthesis, or degenerative disc disease. Fusion for spinal stenosis is 
indicated for a single level with associated spondylolisthesis or other documented instability and symptoms of 
spinal claudication and radicular pain. The pain must represent a significant functional impairment despite a 
history of 3 months of conservative therapy as clinically appropriate. Fusion for degenerative disc disease is 
indicated in the absence of instability when all of the following criteria have been met as clinically appropriate 
for the patients current episode of care: single level degenerative disc disease demonstrated on imaging as the 
likely cause of pain, pain and significant functional impairment despite a history of at least 6 months of 
conservative treatment as clinically appropriate including anti-inflammatory medications, daily exercise, 
activity modification, weight reduction as indicated, and supervised physical therapy. This enrollee presents 
with progressively worsening low back pain radiating into the right lower extremity with associated complaints 
of numbness, tingling and weakness in an L4 dermatomal distribution. He reports significant difficulty with 
walking. He is status post prior lumbar laminectomy on the right at L3/4 and bilaterally at L4/5. There is 
imaging evidence of right greater than left neuroforaminal narrowing at L4/5 with prominent facet hypertrophy, 
and L4 on L5 anterolisthesis with movement documented on flexion/extension films. Detailed evidence of a 
recent, reasonable and/or comprehensive non-operative treatment protocol trial, including physical therapy, 
activity modification, NSAIDs, and epidural steroid injection, and failure has been submitted.  
Under consideration is a request for L4/5 interbody fusion with instrumentation. Medicare coverage indications 
are met in the setting of L4/5 spondylolisthesis with significant radicular pain. He has significant functional 
impairment in ambulation, with evidence of failure of conservative treatment since May 2020. Therefore, the 
enrollee has a covered indication for the requested lumbar spinal fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion for the enrollee have been met. Therefore, we decided that the 
Plan has to pre-approve spinal fusion for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.