Anterior Lumbar Interbody Fusion denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for surgical procedures.Revision spinal surgery following a primary spinal fusion procedure occurs in 8% to 45% of cases. Fusion revision rates are not an uncommon occurrence and are indicated for recurrence of stenosis, non-union, implant failure, infection, adjacent segment degeneration, and flat back fusion. This is further corroborated by another study’s authors, who noted that lumbar spinal fusion is a commonly performed procedure to stabilize the spine, and the frequency with which this operation is performed is increasing. Patients undergoing revision lumbar fusion experience improvements in all patient-reported outcome measures.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) spine surgery and a one day hospital stay. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s low back pain. Findings: There is support in the medical literature for the medical necessity of the requested services in this clinical setting. ALIF is indicated for advanced degenerative disc disease of the lumbar spine and has a high success rate in these cases. Furthermore, it is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine including those with instability.

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: The patient has requested authorization and coverage for S1-2 anterior lumbar interbody fusion (ALIF) and right L5-S1 microdiscectomy (CPT 63030 – laminectomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; CPT 22558 – arthrodesis anterior interbody lumbar; CPT 20930 – allograft for spine surgery only morselized; CPT 22614 – arthrodesis, posterior or posterolateral technique, single level; and CPT 22612 – arthrodesis posterior/posterolateral lumbar) with a two-day inpatient hospital stay. Campbell and colleagues reported a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures.

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 Lumbar Interbody Fusion, then check the rights and deadlines that apply to your plan.