Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay.
The insurer denied the surgical procedures, posterior lumbar interbody fusion (PLIF) at the levels of lumbar vertebrae 3-4 (L3-4) and lumbar vertebrae 4-5 (L4-5) with decompressive laminectomy and 1 inpatient bed stay. as not medically necessary.
The determination is overturned, in part.

The patient is a female with a history of low back pain and bilateral leg pain. She underwent physical therapy, chiropractic therapy, injections and medications without relief. She is a current smoker. The neurologic exam shows left leg weakness. The lumbar magnetic resonance imaging (MRI) shows severe spinal stenosis in lumbar vertebrae 3-4 and moderate to severe foraminal narrowing in lumbar vertebrae 4-5.
At issue is the medical necessity of the requested surgical procedures.

The health plan's determination of medical necessity is overturned, in part.

The lumbar decompression is medically necessary; however, the lumbar fusion is not medically necessary.
The patient has spinal stenosis (lumbar) L3-5 but there is no spondylolisthesis or instability. The literature does not support fusion in this circumstance. Thomes et al cite, "the addition of fusion to decompression did not result in improved outcomes at 3, 12, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity."
The decompression is medically necessary and supported by the literature. Lurie et al cite "in the as-treated analysis combining the randomized and observational cohorts of patients with spinal stenosis (SpS) those treated surgically showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over eight years compared to patients treated non-operatively." The North America Spinal Society (NASS) guidelines state "Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis. Surgical treatment may be considered to provide long-term (4+ years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients."
The 1-day hospital stay for a lumbar decompression is medically necessary due to the length of the surgery, post-operative pain and the use of a post-operative drain.