Diagnosis: Low Back Pain.
Treatment: Outpatient Procedure (Lumbar Spinal Codes 22842 and 22853).

The insurer denied Outpatient Procedure (Lumbar Spinal Codes 22842 and 22853). The denial is upheld.

The patient is a female with primarily low back pain, although she does have some radiating bilateral leg pain. Past surgical history (PSH) is significant for prior spinal cord stimulator placement and removal. The patient has a prior history of tobacco use, but documentation shows she has quit smoking. Physical exam is notable for decreased and painful lumbar range of motion (especially extension) and tenderness in the lower lumbar spine. X-rays show mild scoliosis and advanced decreased disc height lumbar (L)2/3 and moderate disc height loss L3/4. Magnetic resonance imaging (MRI) shows modic changes at L2/3 level. Foraminal and central stenosis at L2/3 and L3/4 due to degenerative changes documented in the clinical notes but the radiology report states no central stenosis at either level and only mild foraminal stenosis. Prior treatments include non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, activity modification, physical therapy (PT), narcotics, muscle relaxers, home exercise program (HEP), spinal cord stimulator. The patient continues to experience symptoms that affect her activities of daily living. She was recommended L2-4 transforaminal lumbar interbody fusions (TLIFs). This was denied by her health plan as not medically necessary due to lack of implant name for concern that Food and Drug Administration (FDA) approved implants are utilized. Addended note documents that the cage is Medtronic Crescent cage and pedicle screws are Nuvasive.

The patient is a female with axial low back pain. While she has failed conservative treatment to date, lumbar fusion surgery has not been shown to reliably treat axial low back pain. The patient has axial low back pain for which lumbar fusion is not recommended. As per Eck et al., "Based on a number of prospective, randomized trials, comparable outcomes, for patients presenting with 1- or 2-level degenerative disc disease, have been demonstrated following either lumbar fusion or a comprehensive rehabilitation program with a cognitive element." Patient's MRI showed significant muscular atrophy and likely would benefit from a comprehensive rehab program as aforementioned.