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 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two level lumbar fusion, with or without cage. 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 but remains controversial in terms of its efficacy, safety, and cost effectiveness versus nonsurgical strategies. In a meta-analysis, Xu and colleagues concluded that spinal fusion was not better than nonoperative treatment for degenerative disc disease with regard to pain and disability and that careful evaluation of the risks of reoperation and the complications of lumbar fusion surgery were needed in such decisions. Yavin and colleagues suggest that lumbar fusion is most efficacious for patients with spondylolisthesis, a condition that this patient does not have.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for posterior sacroiliac joint fusion procedure. Researchers explain, “The sacroiliac joint may be a primary source of pain in patients complaining of low back and/or buttock pain. Nonsurgical treatment of sacroiliac joint pain typically includes structured core and pelvic muscle flexibility and strengthening; pharmaceutical management through oral and injectable medication; and ablation procedures. For patients who do not improve with comprehensive, nonoperative treatment, surgical fusion of the sacroiliac joint is an option with overall good reported outcomes and high patient satisfaction. Minimally invasive surgery (MIS) approaches have been shown to have lower morbidity and earlier recovery than traditional open approaches.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) L5-S1 anterior lumbar interbody fusion surgery and (2) L4-L5 fusion surgery. Medical literature state, “A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.” Researchers state, “Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy.

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