Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, anterior interbody, including disc space 
preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots (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 (22552) and 
anterior instrumentation; 2 to 3 vertebral segments (22845). 
 
You asked the Plan to pre-approve extra fusion operation. You say that the requested procedure is needed due 
to severe pain & spinal cord compression. The Plan denied your request. The Plan says the enrollee has neck 
pain with imaging revealing stenosis. It is not clear based on the imaging and the enrollee's 
symptoms which level(s) are the etiology of the symptoms. The requested surgery is denied because of lack of 
failed conservative treatment in part although there is reference to no response to non-surgical treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 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 extra fusion operation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for radiculopathy of the cervical region. She presented 
with pain in the neck which extends into her bilateral arms down to the hands. The pain has been progressive in 
nature. She has pathology of both C5/6 as well as at C6/7. It is causing compression of the spinal cord and the 
neural foramina. However, detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures to the cervical spine. Additionally, there 
are no clear objective clinical exam deficits related to the cervical spine. There are limited large-scale, long-
term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested anterior cervical discectomy and fusion at C5/6 and C6/7, in 
this case, is not medically reasonable or 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 extra fusion operation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, anterior interbody, including disc space preparation, discectomy, 
osteophytectomy and decompression of spinal cord and/or nerve roots (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 (22552) and anterior instrumentation; 2 to 3 vertebral 
segments (22845).