Diagnosis: Herniated discs.
Treatment: Outpatient services 63030 x 1, 69990 x 1.
The insurer denied coverage for outpatient services 63030 x 1, 69990 x 1.
The denial is upheld.

This case involves an adult under review for lumbar spine surgery. The patient's visit information from the hospital indicated the patient had been seen for sciatica as well as right foot drop. A magnetic resonance imaging (MRI) of the lumbar spine noted disc herniation at lumbar (L)4-5 with minimal central canal stenosis. There was also disc herniation at L3-4 with mild mass effect on the thecal sac. Photos were only partial copies of the MRI and full pathology is unknown.

Current scientific literature supports lumbar decompression surgery when there is evidence of spinal cord and/or nerve root impingement causing neurological deficits unresponsive to conservative measures.

In this case, it was noted that the patient had previously been seen for sciatica and right foot drop. There was also evidence of disc herniations on the MRI. However, the submitted records were photographs of partial reports. Therefore, the full extent of pathology is unknown. In addition, there is no documentation of a comprehensive physical examination to assess neurological findings. There is also a lack of documentation of an adequate course of conservative care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for outpatient services 63030 x 1, 69990 x 1 is not substantiated.