Orthopedic/Musculoskeletal.
Surgical Services.

Diagnosis: Back pain.
Treatment: Spinal Surgery.
The insurer denied spinal surgery. The health plan's determination is upheld.

The patient is a male with a complicated past surgical history in regards to his spine. Apparently, he underwent an L3 to S1 decompression and fusion which included anterior interbody spacers placed at each level. There is also a mention of a revision fusion for "broken hardware" although no specifics are given. He then underwent placement of a SCS (spinal cord stimulator). He re-presented to the provider with a 2-year history of slowly worsening lower back pain and pain into both lower extremities. In the earlier notes, the leg pain seemed to be in the posterior thighs but in later preoperative notes the radicular symptoms were primarily described in the anterior thighs. Multiple attempts at conservative therapy were undertaken including 2 trials of lumbar facet blocks, weight loss, ice and heat, activity modification, physical therapy, and medical management with narcotics and Gabapentin.

The spinal surgery of the lumbar spine, consisting of the LLIF L2-3 and posterior decompression with instrumented fusion and posterolateral fusion, was not medically necessary based on the documentation provided. Generally accepted indications for a spinal fusion is the presence of visible instability at the level(s) planned for a fusion, or the anticipation of creating instability with the extent of the bony removal to ensure complete decompression of the nerves. However, in this case neither gross instability is seen on any imaging study, nor is there the documentation of moderately severe to severe neural foraminal stenosis that would require such bony removal of the facet joints that instability would be created. There was a lack of instability at L2-3 in the flexion/extension views taken at the time of the myelogram, no significant thecal sac compression noted in the radiology report, and only mild canal stenosis and mild to moderate bilateral foraminal stenosis without reported exiting nerve root compression. Thus, the argument that the L2-3 level required such radical decompression that iatrogenic instability would have been created cannot be supported.