Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested services. 

You asked the Plan to pre-approve an artificial cervical disc and cervical fusion. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met. Maximus upheld the Plans denial. You contacted Maximus and stated the wrong service was reviewed. 

Our Medical Director reviewed the reopen request and the case file. Our Medical Director states that our Physician reviewed the appeal for artificial cervical disc and cervical fusion surgery. You are now stating the authorization for a cervical total disc arthroplasty and fusion was not the correct surgery you are trying to obtain authorization for.  You stated "We are requesting a two-level anterior cervical fusion at C3-C4 and C4-C5. There is no artificial disc being used in this case."  

Our Medical Director states that the case file submitted by the Plan identifies the services under appeal as 22551 (Under Anterior or Anterolateral Approach Technique Arthrodesis Procedures on the Spine - in this case, a cervical disc is removed through the front of the neck to help ease spinal pain and related symptoms. Fusion is performed to stabilize the vertebrae) and 22856 (Under Spinal Instrumentation Procedures on the Spine - in this case, an artificial disc is placed into a single cervical interspace. 

The surgeon writes on April 5, 2023, that "the requested anterior cervical decompression at C3-C4, C4-C5; Total disc arthroplasty at C3-C4 and anterior cervical fusion at C4-C5, CPT codes 22856 and 22551." The surgeon also writes, "This is not a request for a two level TDA. It is a one level TDA and a one level fusion."  The appellant's arguments for coverage state, "Codes 22551,22552,20931,22845, and 22853 are all requested as well." This is what is being requested now after the original decision. 

Our Medical Director states the Plan notes in the case file to Maximus that the office was informed that, "because the 22551 and 22845 codes were denied within the last 90 days, they are unable to review the authorization request." Your office states that if the nerves are not decompressed as soon as possible, there is a very real likelihood that the enrollee will lose complete use of his right upper extremity. The Spine Associates note dated March 30, 2023, does state that surgical decompression at C3-C4 and C4-C5 was recommended as an option along with a total disc arthroplasty as an alternative to a fusion. 

Maximus is required to review the case strictly for what the Plan states is under appeal. Based on the records provided Maximus reviewed the case correctly based on the information in the case file submitted by the Plan. 
It appears at this point that you are requesting review for a two-level cervical fusion, under codes 22551, 22552, 20931, 22845, and 22853. These were not the services presented as reviewed by the Plan and we have no other appeals on file for this enrollee. Maximus does not have jurisdiction to review codes the Plan has not completed a full review for. Therefore, our original decision stands.