Lumbar Spinal 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 multi-level lumbar spinal fusion surgery (CPT code 22614) at L4-L5 and L5-S1.Researchers have concluded that lumbar fusion may be considered an option for patients with degenerative disc disease and disc herniations with radiculopathy 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. Authors have 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 that is refractory to nonsurgical care when a diagnosis of disc degeneration can be made. Studies recommend surgery for spinal stenosis for patients who do not improve with conservative treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion. Findings: The physician reviewer found that Evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Wang and colleagues noted that lumbar fusion may be appropriate for patients with degenerative disc disease and disc herniations with radiculopathy 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.

Where the denial was upheld

A 43-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery to remove and replace hardware on an inpatient basis for treatment of the enrollee’s low back and right buttock, leg and groin pain. Findings: The physician reviewer found that in a comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. “References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.” Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies.

A 47-year-old female has requested surgery consisting of lumbar spinal fusion, anterior approach, exploratory retroperitoneal, insertion vertebral device anterior 2-3 segments, application of spine prosthetic device, and extensive fluoroscope exam for treatment of her back and leg pain. Findings: The physician reviewer found that in the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick, et al. examined 389 titles and abstracts. “References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.” Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies.

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