Diagnosis: Low back pain,

Treatment: Back surgery

The insurer denied the coverage for back surgery. The denial was upheld.

This case involves a female patient with a past medical history of low back pain, prolapsed lumbar intervertebral disc, lumbar post laminectomy syndrome, nonunion of spinal fusion and lumbosacral radiculopathy. The patient underwent a laminectomy and fusion from L3-S1. Previous x-ray indicated that the patient had no interval change. There was a posterior fusion from L3-S1 that was again noted and the fractured right side pending nuclear fixation screw at S1 was stable. There was a stable anterior spondylolisthesis of L5 over S1 measuring approximately 3 mm.
An office visit in this current year indicated that was dated indicated that the patient was in the office for follow-up. The patient was complaining of severe pain in the back radiating to the right lower extremity. The patient had a history of nonunion of the lumbar spine fusion with loosening of the screws at the lower end of the construct. The patient was also complaining of severe, right buttock pain. The pain has been getting worse. The physical examination revealed there was a healed, midline incision longitudinal in nature. The patient had lumbar spine tenderness in the paravertebral region bilaterally with decreased range of motion. The patient had pain with range of motion. The motor strength was intact. Reflexes were absent bilaterally. Straight leg raise was positive on the right at 30 degrees. The provider stated that the patient had not responded to conservative care. Because of the patient's severe, unremitting pain, the provider was to try and schedule surgery for the lumbar spine for the repair of nonunion with extension of the fusion to L2.

There was a lack of documentation of identification of findings specifically starting at L2-3 and no specific dermatomal or myotomal findings were noted to support surgical intervention at all of the requested levels. Therefore, the healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.