Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that this surgery is medically necessary. The Plan 
denied your request. The Plan says although hardware removal was approved, the requested spinal surgery is 
not medically necessary. Evidence-based criteria states that the patient must have pseudoarthrosis (a failure of 
bones to fuse after spinal surgery) and the imaging findings must correlate with those signs and symptoms. The 
documentation submitted does not support these criteria; therefore, the requested back surgery is not reasonable 
or necessary. 
 
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 spinal surgery. Our reviewer says that 
the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found a trial of conservative therapy may be considered for patients with low-grade spondylolisthesis 
presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural 
steroid injection, and pain medications.  
 If unresolved, surgical options may include decompression alone or decompression and fusion. Patients with 
symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, 
but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal 
injections, and physical therapy. For well-selected patients who fail conservative management strategies, 
surgical management is appropriate. As a result of the decompression, the inherent instability associated with 
the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of 
neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the 
spine and prevent delayed deterioration. Lumbar degenerative spondylolisthesis (DS) is a common cause of 
low back pain, radiculopathy, and/or neurogenic claudication. Treatment begins with a trial of nonsurgical 
methods, including physical therapy, medication, and epidural corticosteroid injections. Surgical treatment with 
decompression and fusion is recommended for patients who do not respond to this initial regimen. Although 
much has been published in the past two decades on the surgical management of DS, the optimal method 
remains controversial. Interbody fusion may improve arthrodesis rates and can be performed via numerous 
surgical approaches. Minimally invasive techniques continue to be developed. Particular attention to surgical 
management of DS in the elderly is warranted given the increasing numbers of elderly persons. Healthcare 
utilization in the future must take into account evidence-based medicine that establishes clinically effective 
practices while simultaneously being cost effective. Among patients with degenerative grade I 
spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but 
clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone.  
 
The doctor says that this patient is being treated for pseudarthrosis after fusion or arthrodesis.  She presented 
with right lower back pain that is non-radiating. The pain is rated at 6/10. However, detailed documentation is 
not evident regarding instability of the lumbar spine corroborated by the imaging studies. The x-rays provided 
for review do not show that there is pseudoarthrosis of the previous fusion at L4-5. The magnetic resonance 
imaging demonstrated prior partial laminectomies, unchanged symmetric disc bulge and osteophyte, and no 
spinal stenosis. Segmental instability and/or inevitable temporary intraoperative instability has not been 
documented. The objective findings documented on the exams did not demonstrate any neurological deficits. 
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 to guidelines. Therefore, the requested back surgery, 
lumbar fusion, 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 spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.