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202209-153608

2022

Fidelis Care New York

HMO

Central Nervous System/ Neuromuscular Disorder

Surgical Services

Medical necessity

Upheld

Case Summary

Diagnosis: Back Pain,
Treatment: Inpatient surgery (lumbar fusion [CPT 20939, 22612, 22633, 22840, 22853, 63047, 63052 x1]).
The insurer denied: Inpatient surgery (lumbar fusion [CPT 20939, 22612, 22633, 22840, 22853, 63047, 63052 x1]).
The denial is upheld.

The patient is an adult male with back pain and a history of L (lumbar) 4-L5 multiple epidural steroid injections last year and this year. The patient takes multiple medications for pain. According to an appeal letter from the attending physician, the patient "has tried oral medications, at home therapy exercises, activity modification including rest, and steroid injections..." The patient's exam reveals no focal deficit. His magnetic resonance image (MRI) shows L4-L5 facet arthropathy but no noted stenosis with normal alignment. The patient was recommended for L4-L5 transforaminal lumbar interbody fusion (TLIF).

The proposed inpatient surgery (lumbar fusion) is not medically necessary.

Although the patient is stated to have tried medications, home therapy, activity modification and injections, the patient's imaging does not demonstrate a significant pathology that would warrant the fusion that was recommended. The patient's magnetic resonance image (MRI) shows L4-L5 facet arthropathy but there is no noted stenosis at any level. Therefore, the lumbar fusion is not considered medically necessary.

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