Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old male with a history of low back pain and left-sided sciatic pain for which he underwent L4-5 microdiscectomy on 2/7/15 with an initial good result. The patient sustained a fall in July 2015 and experienced recurrence of symptoms with low back and left radicular pain and numbness radiating posterolaterally to the left foot. Magnetic resonance imaging (MRI) scan demonstrated L4-5 grade 1 retrolisthesis with moderate left worse than right foraminal stenosis and L5-S1 disc protrusion with left foraminal stenosis and left L5 nerve root contact. He had a left L4-5 epidural steroid injection which gave him 100% relief for two days. He then had two injections on the left at L4-5 and one injection on the left at L5-S1, which gave him 50% relief. He does feel weakness of the left lower extremity and occasional unsteadiness with ambulation. Progress notes dated 7/13/16 document negative straight leg raising bilaterally. His gait was normal. His strength was 4+/5 in the left plantar flexors and hamstrings and decreased sensation to light touch over the left lateral thigh, lateral leg, medial and lateral foot. The patient has failed many months of conservative therapy including multiple injections, medications, and is currently on narcotic medications. The provider recommended surgery to include L4-5 and L5-S1 facetectomies on the left. Due to the decompression with need for facetectomies, L4-5 spondylolisthesis instability would be created necessitating a fusion from L4-S1. The provider is requesting anterior/posterior fusion from L4-S1. The patient has requested authorization and coverage for lumbar fusion (22558, 20936, 22840, 22612, 22851, 63048, 20930, 22585, 22614, and 63042). The Health Insurer denied the request for surgery in the absence of documented instability, infection, tumor, or spinal stenosis. This denial is the subject of this appeal and determination. The medical literature supports the medical necessity for the requested services in this clinical setting. Yavin and colleagues summarized the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications. The authors reported that disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression alone, the risk of reoperation following fusion was increased for spinal stenosis and decreased for spondylolisthesis. In this patients case, the fusion is being performed for iatrogenic instability that will be created upon decompression for degenerative spondylolisthesis and associated neural compression. The provider is planning two level facetectomies at L4-5 and L5-S1 on the left, which will necessitate a stabilization procedure. All told, the requested lumbar fusion (22558, 20936, 22840, 22612, 22851, 63048, 20930, 22585, 22614, and 63042) is supported as medically necessary for treatment of this patients medical condition.  Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.