Lumbar 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 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000). Wood and colleagues recommended that fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. Researchers support surgery for spinal stenosis in patients who do not improve with conservative treatment. The authors noted that the inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Studies concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain refractory to nonsurgical care in the setting of disc degeneration.

Where the denial was upheld

An enrollee has requested authorization and coverage for lumbar fusion-multiple levels: decompression and fusion.Rao and colleagues have found that anterior lumbar interbody fusion (ALIF) is an effective treatment for degenerative disc disease (with and without radiculopathy) or spondylolisthesis. Further studies were recommended, however, to establish the effectiveness of ALIF for scoliosis, failed posterior fusion, and adjacent segment disease. Wang and colleagues have supported the consideration of lumbar fusion for patients with degenerative disc disease and disc herniations with radiculopathy, based on low level evidence when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery for treatment of the enrollee’s low back pain. Findings: The physician reviewer found that Evidence based medical guidelines and peer reviewed criteria have not been met in this patient’s case. Current evidence based medical guideline criteria for lumbar decompression include symptoms/findings that confirm the presence of radiculopathy and correlate with clinical examination and imaging findings. Guidelines do not recommend lumbar fusion for patients with degenerative disc disease, disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or non-specific low back pain.

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