Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve removal of posterior segmental instrumentation (22852) and insertion of intervertebral biomechanical device (22859). We decided that the Plan does not have to pre-approve fusions of additional levels (22614), exploration of spinal fusion (22830) and anterior instrumentation (22847). 

You asked the Plan to pre-approve spinal fusion surgery services.. You say that the requested services are a medical necessity for you. The Plan says that the requested services are not medically necessary.

 
We decided that the Plan has to pre-approve removal of posterior segmental instrumentation (22852) and insertion of intervertebral biomechanical device (22859). 

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 removal of posterior segmental instrumentation (22852) and insertion of intervertebral biomechanical device (22859). Our reviewer says that these services are medically reasonable and necessary in this case. Our physician reviewer found that revision surgery with extensive long fusion above and below with interbody grafting and decompression is needed. The original hardware needs to be removed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of removal of posterior segmental instrumentation (22852) and insertion of intervertebral biomechanical device (22859) have been met. Therefore, we decided that the Plan has to pre-approve removal of posterior segmental instrumentation (22852) and insertion of intervertebral biomechanical device (22859). 

We also decided that the Plan does not have to pre-approve fusions of additional levels (22614), exploration of spinal fusion (22830) and anterior instrumentation (22847).

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 fusions of additional levels (22614), exploration of spinal fusion (22830) and anterior instrumentation (22847). Our reviewer says that these services are not medically reasonable and necessary. Our physician reviewer found the exploration of fusion, additional levels of fusion and anterior instrumentation for 8 levels are not needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fusions of additional levels (22614), exploration of spinal fusion (22830) and anterior instrumentation (22847) have not been met. Therefore, we decided that the Plan does not have to pre-approve fusions of additional levels (22614), exploration of spinal fusion (22830) and anterior instrumentation (22847).

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.