Vertebral Disc Prob: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement surgery by anterior approach (CPT code 22857). The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L4-L5 minimally invasive intradiscal lumbar interbody fusion (MIS-IntraLIF) with L4-5 facetectomies and discectomy, intrafacet and interbody autograft-allograft arthrodesis, and placement of interbody mechanical device. Treatment of low back pain with lumbar fusion, in the absence of instability, trauma, tumor, or fracture is and has been a very common practice although controversy remains in terms of its efficacy, safety, and cost effectiveness. The main question explored in current medical literature is whether lumbar spinal fusion surgery is better than nonoperative management in patients who have already tried and failed long-term exhaustive conservative management.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided. Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) four cervical levels (two levels approved by plan and two levels denied by plan) of artificial disc replacement (ADR) (CPT 22856) and (2) four lumbar levels (one level approved by plan, and three levels denied by plan) of ADR (CPT 0163T). In this clinical setting, four cervical levels of ADR are not likely to be more beneficial than any available standard treatment for this patient’s medical condition. In a prospective, randomized, controlled multicenter clinical trial on two-level symptomatic degenerative disc disease, Davis and colleagues noted findings supporting the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for vertebral disc prob was denied, the published record says the denial is worth fighting.