Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, combined posterior or posterolateral 
technique with posterior interbody technique including laminectomy and/or discectomy (22633, 22634), 
laminectomy, facetectomy, or foraminotomy with lumbar decompression of spinal cord, cauda equina and/or 
nerve root during posterior interbody arthrodesis (63052,63053), internal spinal fixation by wiring of spinous 
processes (22842), insertion of interbody biomechanical device(s) with integral anterior instrumentation for 
device anchoring, when performed, to (22853), arthrodesis, sacroiliac joint (27280), stereotactic computer-
assisted procedure; spinal (61783), autograft for spine surgery only; local obtained from same incision (20936), 
allograft, spine surgery only; morselized (20930).  
You asked the Plan to pre-approve L3-4, L4-5, and L5-S1 laminectomy, facetectomy, transforaminal lumbar 
interbody fusion, L3-pelvis instrumented fusion, posterolateral arthrodesis, and open fusion of the bilateral 
sacroiliac joints. You say that this procedure is medically necessary. The Plan denied your request. The Plan 
says the studies do not show that this procedure provides any additional benefit. 
 
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 L3-4, L4-5, and L5-S1 laminectomy, 
facetectomy, transforaminal lumbar interbody fusion, L3-pelvis instrumented fusion, posterolateral arthrodesis, 
and open fusion of the bilateral sacroiliac joints. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the provided x-
rays with flexion/extension view did not corroborate any dynamic instability at the requested surgical levels, or 
any level. Detailed documentation is not evident regarding potential impending/inevitable temporary intra-
operative instability. Additionally, there is no imaging or radiographic evidence supporting a sacroiliitis 
pathology. There is no clear history of SI joint pain onset or failure of conservative treatment directed to the SI 
joint. Multiple other plausible pain generators including at the lumbosacral spine are also evident. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. Moreover, there are no large volume, long-term/high-quality clinical studies confirm the 
clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted 
surgery over standard surgical approaches in lumbar spinal surgeries. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested L3-4, L4-5, and L5-S1 laminectomy, facetectomy, transforaminal lumbar interbody 
fusion, L3-pelvis instrumented fusion, posterolateral arthrodesis, and open fusion of the bilateral sacroiliac 
joints 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 L3-4, L4-5, and L5-S1 laminectomy, facetectomy, transforaminal lumbar 
interbody fusion, L3-pelvis instrumented fusion, posterolateral arthrodesis, and open fusion of the bilateral 
sacroiliac joints have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including 
laminectomy and/or discectomy (22633, 22634), laminectomy, facetectomy, or foraminotomy with lumbar 
decompression of spinal cord, cauda equina and/or nerve root during posterior interbody arthrodesis 
(63052,63053), internal spinal fixation by wiring of spinous processes (22842), insertion of interbody 
biomechanical device(s) with integral anterior instrumentation for device anchoring, when performed, to 
(22853), arthrodesis, sacroiliac joint (27280), stereotactic computer-assisted procedure; spinal (61783), 
autograft for spine surgery only; local obtained from same incision (20936), allograft, spine surgery only; 
morselized (20930).