Anterior Cervical Discectomy And Fusion denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cervical spine surgery (artificial disc replacement at C4-5 and C5-6 and foraminotomy with anterior cervical discectomy and fusion (ACDF) at C7-T1). Findings: The physician reviewer found that Boddapati and colleagues have noted that many patients with multilevel disease are not good candidates for cervical disc arthroplasty (CDA) at all levels. For such patients, hybrid surgery, a combination of adjacent anterior cervical discectomy and fusion (ACDF) and CDA, may be more appropriate. They concluded that patients undergoing hybrid surgery are not at increased risk of perioperative complications relative to a 2-level ACDF and may benefit from shorter length of stay.

Nature of Statutory Criteria/Case Summary: The enrollee requested spinal surgery through anterior instrumentation for two to three vertebral segments. The records provided for review indicate that the patient has been treated for cervical disc disorder at the C6-7 level with radiculopathy. A study noted that anterior cervical discectomy and fusion (ACDF) is recommended for patients with cervical disc disorder with radiculopathy who have failed treatment with conservative measures. Additional studies support the requested procedure indicating ACDF “is a proven treatment for patients with stenosis and disc herniation and results in significantly improved short- and intermediate-term outcomes”. This is further supported by other authors who concluded “ACDF is the most commonly performed surgical procedure for degenerative cervical spine disease.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF). In a review by researchers, the authors assert that cervical disc disease includes chronic disc degeneration, stenosis, spondylosis, and disc herniation. The authors noted that these conditions are initially treated conservatively through symptomatic care and that surgery may be indicated when conservative measures fail.

A 61-year-old male enrollee has requested neck surgery, brand name medications Percocet and Norco, and Carisoprodol and Diazepam 10 mg for treatment of his neck pain. Findings: The physician reviewer found that review of the submitted documentation demonstrates the patient would not benefit from the continued use of Percocet, Norco, Carisoprodol, and Diazepam given the lack of any significant relief to warrant continued use, in addition to the presence of significant risk factors.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Anterior Cervical Discectomy And Fusion, then check the rights and deadlines that apply to your plan.