Is an anterior cervical disc fusion (ACDF) C4-5, C5-6 medically necessary for a 51-year-old female patient with neck pain and cervical radiculopathy in the right C5-C6 distribution due to a C4-5 herniated disc and C5-6 severe foraminal stenosis, who has failed conservative measures and has significant limitations in activities of daily living?

Medical Necessity Determination for Two-Level ACDF C4-5, C5-6

This two-level ACDF C4-5, C5-6 is medically necessary and meets all established clinical criteria for surgical intervention. 1

Primary Surgical Indication - FULLY MET

This patient presents with the classic triad justifying anterior cervical decompression: severe radiculopathy with objective motor weakness (deltoid weakness indicating C5 nerve compression), imaging-confirmed neural compression at the symptomatic levels, and failed conservative management. 2, 1

Clinical Correlation - CONFIRMED

• C4-5 level: Right paracentral disc extrusion with moderate canal narrowing, cord abutment/flattening, and mass effect on the exiting right C5 nerve rootlets directly correlates with the patient's right deltoid weakness and C5 distribution symptoms 1
• C5-6 level: Severe left foraminal stenosis (though the clinical presentation describes right-sided symptoms, the severe stenosis at this level combined with mild right foraminal narrowing and the patient's symptoms radiating past the elbow to hand/fingers supports C6 nerve involvement) 1
• The presence of objective motor weakness (deltoid weakness, inability to raise arm, "useless" arm function) elevates this beyond simple radiculopathy to a more urgent surgical indication 1

CPB 0743 Criteria Analysis - ALL MET

1. Other Sources of Pain Ruled Out - MET

• MRI specifically identifies pathology at C4-5 and C5-6 corresponding to clinical symptoms 1
• No mention of significant pathology at other cervical levels that would confound surgical planning 1

2. Signs/Symptoms of Neural Compression - MET

• Severe radiculopathy in right C5 and C6 distributions with pain radiating past elbow to hand/fingers 2, 1
• Objective motor deficit: notable deltoid weakness with difficulty maintaining arm elevation 1
• Previous sensory symptoms (numbness/tingling in fingers, cold hand) 1
• Pain worsened by neck movement and shoulder elevation (classic radicular pattern) 1

3. Advanced Imaging Shows Appropriate Stenosis Grade - MET

• C4-5: "Moderate canal narrowing" with cord abutment/flattening and disc extrusion - exceeds the "moderate" threshold required by CPB 1
• C5-6: "Severe left foraminal narrowing" explicitly documented - clearly meets severity criteria 1
• The CPB requires "moderate, moderate to severe or severe" stenosis (NOT "mild or mild to moderate") - both levels meet this standard 1

4. Conservative Management Failed - MET

• Physical therapy within past 6 months documented 3
• Medical therapies including gabapentin trialed without adequate relief 3
• Two emergency room visits for current issue indicating severity 1
• The patient meets the minimum 6-week conservative therapy requirement before surgical consideration 2, 1

5. ADL Limitations - MET

• Inability to wash hair 1
• Driving severely limited due to pain with head turns 1
• Requires brace for sleep 1
• Arm described as "useless" with severe functional impairment 1
• These represent profound ADL limitations justifying surgical intervention 1

Specific CPT Code Justification

22551 (Primary Anterior Cervical Fusion) - APPROVED

• First level (C4-5) meets all criteria for anterior cervical decompression and fusion 1

22552 (Additional Level) - APPROVED

• Second level (C5-6) independently meets severity criteria with severe foraminal stenosis 1
• Both levels demonstrate pathology requiring surgical treatment 1

22845 (Anterior Instrumentation/Plating) - APPROVED

• For two-level cervical fusion, anterior cervical plating is strongly recommended to reduce pseudarthrosis risk from 4.8% to 0.7% and improve fusion rates from 72% to 91% 1
• Instrumentation maintains cervical lordosis and provides greater stability in multilevel constructs 1
• Per AHH internal guidelines exception, pedicle screws may be certified with any spinal fusion when the fusion surgery meets criteria - this is met 1

22853 x 2 (Interbody Biomechanical Devices/Cages) - REQUIRES CLARIFICATION

Critical CPB 0016 Analysis: The CPB policy for synthetic spine cages/spacers in cervical fusion lists specific indications, and this case does NOT clearly meet the stated criteria:

• Cervical corpectomy indication: The case describes discectomy, not corpectomy (removal of half or more of vertebral body) 1
• Symptomatic central canal stenosis from vertebral body pathology: While C4-5 has moderate canal narrowing, this is from disc extrusion, not vertebral body pathology (fracture, tumor, deformity) 1
• Pseudarthrosis revision: Not applicable - this is primary surgery 1
• Adjacent level disease with prior plate: Not applicable - no prior cervical fusion 1

However, standard surgical practice for ACDF universally employs interbody spacers/cages to maintain disc height and provide structural support, which is critical for foraminal decompression. 1, 4 The CPB language may be outdated or overly restrictive compared to contemporary surgical standards where cages are considered standard of care for ACDF procedures. 4

Recommendation: Request clarification from the payer regarding whether interbody devices are considered standard components of ACDF or require the specific indications listed in CPB 0016. If denied, consider appealing based on standard surgical practice and the necessity of maintaining disc height for neural decompression. 1, 4

20930 (Allograft Morselized) - APPROVED

• CPB 0411 explicitly states cadaveric allograft and demineralized bone matrix are medically necessary for spinal fusions 1
• Allograft materials that are 100% bone are considered medically necessary regardless of shape 1

20936 (Autograft) - APPROVED

• Autograft remains an accepted graft material for cervical fusion with comparable fusion rates to allograft (97% vs 94%) 2
• MCG criteria met for "other spinal procedure required" 1

Surgical Approach Rationale

Anterior approach (ACDF) is the optimal surgical choice for this patient rather than posterior laminoforaminotomy because: 1

• C4-5 has central/paracentral disc extrusion with cord compression - anterior decompression directly addresses ventral pathology 1
• ACDF provides more rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to conservative management 1, 3
• Success rates for arm pain relief with ACDF range from 80-90% with 90.9% functional improvement 1
• Two-level disease benefits from the stability provided by anterior plating 1

Expected Outcomes and Prognosis

• 80-90% success rate for arm pain relief with ACDF 1
• 90.9% functional improvement expected 1
• More rapid symptom resolution (3-4 months) compared to continued conservative management 1, 3
• The addition of anterior plating for two-level fusion significantly reduces pseudarthrosis risk and improves fusion rates 1

Critical Pitfalls to Avoid

• Do NOT delay surgery further - the patient has objective motor weakness (deltoid weakness) which represents a more urgent indication than radicular pain alone 1
• Ensure documentation of conservative therapy duration is clearly stated in medical records (appears met with "physical therapy within past 6 months" and medication trials) 1
• Confirm imaging severity grading - both levels must meet "moderate" or greater stenosis threshold, which they do (C4-5 moderate canal narrowing, C5-6 severe foraminal stenosis) 1
• Address the cage/spacer CPB discrepancy proactively with the payer before surgery to avoid post-operative denial 1

Postoperative Considerations

The patient will require progressive physical therapy for both cervical and shoulder function, with a home exercise program to prevent frozen shoulder recurrence given the concomitant adhesive capsulitis from prolonged immobilization. 1