Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve spinal surgery (22551, 22552, 22845, and 22853). 
 
You asked the Plan to pre-approve spinal surgery. You say that the requested spinal surgery is medically 
necessary. The Plan denied your request. The Plan says that the requested spinal surgery is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 surgery. Our reviewer says that 
the requested spinal surgery is medically necessary. Our physician reviewer found the enrollee was being 
treated for spinal stenosis of the cervical region. He continues to have neck pain radiating to the upper 
extremities. The pain is rated at a 6 and is constant and achy. The exam reveals intact strength and sensation of 
the upper and lower extremities bilaterally. There is 50% of the expected range of motion of the cervical spine. 
There is mild palpable tenderness to the posterior cervical spine. 
 
Despite the lack of objective neurological deficits on the most recent exam provided from May 17, 2022; 
imaging revealed probable C6 screw being fractured. This represents a plausible non-united prior fusion. C6-7 
revealed diffuse disc bulge with borderline mild spinal canal stenosis. C7-T1 revealed disc space narrowing. 
There are extenuating circumstances noted to support the medical necessity of this request as an exception. 
This is due to the medical necessity to treat the painful radiculitis and probable cervical fusion non-union. The 
adjacent levels of C6-7 and C7-T1 are appropriate for similar fusion treatment for the same rationale, along 
with the medical necessity to add greater stability to treat the non-united fusion.  
 
Therefore, the requested arthrodesis, anterior interbody, including disc space preparation, discectomy, 
osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 (CPT 22551); 
arthrodesis, anterior interbody including disc space preparation, discectomy, osteophytectomy and 
decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (CPT 22552); 
anterior instrumentation; 2-3 vertebral segments (CPT 22845); and insertion of interbody biomechanical 
device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, 
flanges), when performed to intervertebral disc space in conjunction with interbody arthrodesis, each interspace 
(CPT 22853), in this case, is medically reasonable and necessary. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve spinal surgery (22551, 22552, 22845, and 22853).  
 
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.