Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical arthrodesis anterior interbody, an insertion of 
interbody biomechanical device, the removal of anterior instrumentation, a spinal fixation device, an autograft 
for spine surgery only, and a bone allograft.  
 
  You asked the Plan to pre-approve  a cervical arthrodesis anterior interbody, an insertion of interbody 
biomechanical device, the removal of anterior instrumentation, a spinal fixation device, an autograft for spine 
surgery only and a bone allograft. You say that the enrollee needs the procedure to fix and repair spinal stenosis 
that is affecting their mobility and day to day life. The Plan denied your request. The Plan says a cervical 
arthrodesis anterior interbody, an insertion of interbody biomechanical device, the removal of anterior 
instrumentation, a spinal fixation device, an autograft for spine surgery only and a bone allograft.  are not 
medically 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 a cervical arthrodesis anterior 
interbody, an insertion of interbody biomechanical device, the removal of anterior instrumentation, a spinal 
fixation device, an autograft for spine surgery only and a bone allograft. Our reviewer says that a cervical 
arthrodesis anterior interbody, an insertion of interbody biomechanical device, the removal of anterior 
instrumentation, a spinal fixation device, an autograft for spine surgery only and a bone allograft.  are not 
medically necessary. Our physician reviewer found the documentation is not evident regarding a formal 
objective physical exam to corroborate findings consistent with the demonstrate pathology on the magnetic 
resonance imaging study. Moreover, the enrollee is noted to be a current everyday smoker which is a relative 
contraindication for fusion procedures due to the associated surgical complications and delayed healing. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested inpatient anterior cervical fusion from C5-6 with synthetic 
cage and spacer and removal of anterior instrumentation from C6-7 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 a cervical arthrodesis anterior interbody, an insertion of interbody 
biomechanical device, the removal of anterior instrumentation, a spinal fixation device, an autograft for spine 
surgery only and a bone allograft.  have not been met. Therefore, we decided that the Plan does not have to pre-
approve a cervical arthrodesis anterior interbody, an insertion of interbody biomechanical device, the removal 
of anterior instrumentation, a spinal fixation device, an autograft for spine surgery only and a bone allograft.