Is anterior cervical discectomy and fusion (ACDF) at C4-C5 and C6-7 medically indicated for a patient with cervical myelopathy and severe spinal stenosis?

ACDF at C4-C5 and C6-7 is Medically Indicated

This patient meets all criteria for anterior cervical discectomy and fusion at both C4-C5 and C6-7, and the surgery should be approved without delay given the presence of cervical myelopathy with progressive neurological deterioration. 1, 2

Critical Clinical Justification

This 45-year-old female presents with cervical myelopathy, which is a surgical emergency that requires intervention to prevent catastrophic spinal cord injury. 3 The clinical presentation is compelling:

• Positive Hoffmann's sign indicates upper motor neuron involvement and spinal cord compression 2, 3
• Complete weakness of the left upper extremity represents severe neurological compromise requiring urgent decompression 2
• Bilateral handgrip weakness with gait imbalance demonstrates myelopathic progression 3
• Acute neurological deterioration (complete arm numbness following emergency department visit on 08/03/2025) indicates unstable myelopathy 3

Policy Criteria Analysis - All Requirements Met

Level C4-C5 Justification:

• Moderate central stenosis on CT meets the "moderate, moderate to severe, or severe" threshold required by policy 1
• Bilateral neural foraminal narrowing documented on imaging 1
• Clinical symptoms correlate with multilevel compression 1, 2

Level C6-C7 Justification:

• Severe spinal stenosis on MRI (07/29/2025) clearly exceeds policy requirements 1
• Moderate central stenosis confirmed on CT (09/17/2025) 1
• This level demonstrates the most severe pathology and directly correlates with myelopathic symptoms 2

Conservative Management Requirements - Satisfied:

• 6+ weeks of conservative therapy completed including cyclobenzaprine, gabapentin, meloxicam, and physical therapy (06/2025) 1
• Patient has failed conservative management as evidenced by progressive neurological deterioration despite medications 2, 3
• The American Association of Neurological Surgeons recommends surgical intervention for patients with persistent symptoms despite 6+ weeks of conservative treatment 1

Activities of Daily Living Impact - Documented:

• Difficulty lifting objects since January 2025 1
• Complete weakness of left upper extremity severely limits function 2
• Gait imbalance impairs mobility and increases fall risk 3

Surgical Approach and Expected Outcomes

ACDF provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative therapy, with 80-90% success rates for neurological improvement. 1, 2, 4

Multilevel Fusion Rationale:

• Both C4-C5 and C6-C7 meet severity criteria independently and contribute to the myelopathic presentation 1, 2
• Multilevel ACDF (2 levels) is appropriate when pathology exists at all levels being treated 2
• Four-level ACDF studies demonstrate 88.3% patient improvement with 95% fusion rates, supporting the safety of multilevel anterior approaches 4

Instrumentation Medical Necessity:

• Anterior cervical plating is medically necessary for 2-level fusion to reduce pseudarthrosis risk and maintain cervical lordosis 1, 2
• The addition of anterior plating improves fusion rates and provides greater stability in multilevel disease 1, 2
• Per policy exception, pedicle screws (CPT 22845) may be certified with any spinal fusion that meets criteria 2

Critical Pitfalls to Avoid

Do not delay surgery in myelopathic patients. 3 The natural history of cervical myelopathy is stepwise neurological deterioration, and patients with untreated myelopathy are at high risk for progressive deficits. 3 This patient's history of acute neurological events (complete arm numbness on 08/03/2025) combined with positive Hoffmann's sign and gait imbalance indicates unstable myelopathy requiring urgent intervention. 3

Do not require additional conservative therapy. 1 The patient has already completed 6+ weeks of multimodal conservative management (medications since symptom onset in January 2025, physical therapy in June 2025), and has demonstrated progressive deterioration despite treatment. 1, 2

Surgical intervention is indicated to prevent catastrophic spinal cord injury that could occur with falls or trauma, which is particularly concerning given this patient's documented gait imbalance. 3

Bone Graft and Hardware Approval

• Cadaveric allograft and demineralized bone matrix are medically necessary for spinal fusion per policy 0411 1
• Interbody cage devices (CPT 22853 x2) are medically necessary to provide immediate structural support and maintain disc height for foraminal decompression 1
• Anterior cervical plating (CPT 22846) meets medical necessity criteria for 2-level fusion 1, 2

Artificial Disc Consideration - Not Applicable

While the policy includes criteria for cervical disc arthroplasty, ACDF is the appropriate procedure for this patient given the presence of myelopathy, multilevel disease, and moderate-to-severe stenosis. 1, 2 Artificial disc replacement is contraindicated in patients with significant stenosis requiring decompression at multiple levels. 1