Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Surgical Services.
The insurer denied back surgery.
The denial is upheld.

The patient is a male who underwent bilateral decompressive laminectomy of the lumbar spine at thoracic (T)8-T9 with decompression of spinal cord and nerve roots bilaterally with bilateral posterior instrumentation of the thoracic spine at T7, T8, T9 and T10 and bilateral posterior transverse fusion T7-T10 using allograft, autograft and Trinity bone graft with computer assisted navigation and neurophysiological monitoring. His diagnoses listed herniated disc, degenerative disc disease thoracic spine, thoracic spondylosis, and thoracic radiculopathy. The subject under review is the medical necessity for back surgery.

The health plan's determination is upheld in whole.

The requested back surgery is not medically necessary. Medical records fail to show the patient's subjective complaints, exams, conservative treatments prior to surgery and imaging reports. There is no indication for surgery in the operative report. The requested current procedural terminology (CPT) codes do not meet general guidelines and standard of care and are not medically necessary.