Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of posterior segmental instrumentation 
(22852), exploration of spinal fusion (22830), arthrodesis (22633, 22634), laminectomy, facetectomy, or 
foraminotomy (63052, 63053), posterior non-segmental instrumentation (22840, 22842), an allograft (20930), 
an autograft (20936), insertion of interbody biomechanical device (22853), stereotactic computer-assisted 
(navigational) procedure; spinal (61783). 
 You asked the Plan to pre-approve removal of posterior segmental instrumentation, exploration of spinal 
fusion, arthrodesis, laminectomy, facetectomy, or foraminotomy, posterior non-segmental instrumentation, an 
allograft, an autograft, insertion of interbody biomechanical device, stereotactic computer-assisted 
(navigational) procedure; spinal . You say that this is medically necessary. The Plan denied your request. The 
Plan says the requested services are experimental, investigational, and unproven. 
 
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 removal of posterior segmental 
instrumentation, exploration of spinal fusion, arthrodesis, laminectomy, facetectomy, or foraminotomy, 
posterior non-segmental instrumentation, an allograft, an autograft, insertion of interbody biomechanical 
device, stereotactic computer-assisted (navigational) procedure; spinal . Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. The enrollee is noted to have failed conservative treatments, but 
these are not clearly noted. Moreover, dynamic flexion/extension films are not provided in order to potentially 
assess the amount of movement (instability) at all of the requested surgical levels. Detailed documentation is 
not evident regarding potential impending/inevitable temporary intra-operative instability. No compelling 
rationale is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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, exploration of spinal fusion, 
arthrodesis, laminectomy, facetectomy, or foraminotomy, posterior non-segmental instrumentation, an 
allograft, an autograft, insertion of interbody biomechanical device, stereotactic computer-assisted 
(navigational) procedure; spinal  have not been met. Therefore, we decided that the Plan does not have to pre-
approve removal of posterior segmental instrumentation (22852), exploration of spinal fusion (22830), 
arthrodesis (22633, 22634), laminectomy, facetectomy, or foraminotomy (63052, 63053), posterior non-
segmental instrumentation (22840, 22842), an allograft (20930), an autograft (20936), insertion of interbody 
biomechanical device (22853), stereotactic computer-assisted (navigational) procedure; spinal (61783).