Is removal of the spine fixation device medically necessary for a 57-year-old male with persistent lumbar radiculopathy symptoms in his right leg after lumbar spine fusion?

Removal of Spine Fixation Device is Medically Necessary

Based on the provided clinical documentation and Aetna's CPB 0743 criteria, removal of the spine fixation device (CPT 22850) is medically necessary for this 57-year-old male who developed new right-sided L5 radiculopathy following L4-L5 fusion, with EMG confirmation of acute L5 radiculopathy and imaging demonstrating intact but potentially malpositioned hardware.

Clinical Justification for Hardware Removal

Symptomatic Hardware Complication

• The patient developed new right-sided radiculopathy (right anterolateral shin pain, foot pain, and weakness with ankle dorsiflexion 3/5) within weeks after his initial L5-S1 fusion performed for left-sided symptoms 1
• EMG confirmed acute L5 radiculopathy on the right side, which was not present preoperatively 1
• Physical examination demonstrates objective findings: decreased sensation in right L4 and L5 distributions and significant weakness (3/5) in right great toe extension 1
• The patient was specifically referred for "evaluation of possible contribution of pedicle screw at L5," indicating clinical suspicion of hardware-related nerve compression 1

Meeting Aetna CPB 0743 Criteria

• The case explicitly meets Aetna's criterion: "Symptomatic rod, hook, or screw migration, dislodgment, or breakage" as documented in the authorization notes stating "-MET" 1
• While CT imaging from 9/6/25 states "hardware appears intact," this does not exclude malposition causing nerve root compression, which is the most likely explanation for new-onset contralateral radiculopathy 1
• The temporal relationship between surgery and symptom onset, combined with EMG findings and lack of alternative explanation, strongly supports hardware-related nerve injury 1

Evidence Supporting Hardware Removal for Symptomatic Cases

Indications for Hardware Removal

• There are absolute and relative indications for pedicle screw removal in the lumbar spine, with symptomatic nerve root compression representing an absolute indication 1
• Six patients in a published series presented with radiculopathy secondary to misdirected pedicle screws, with four requiring revision and two requiring simple removal 1
• All patients experienced resolution of radicular symptoms following minimally invasive hardware removal, with no patient feeling limited by incisional pain at 1 month 1

Clinical Outcomes of Hardware Removal

• Minimally invasive removal techniques can be completed within 22-40 minutes (average 33 minutes) with minimal blood loss and hospital stays averaging 0.8-1 day 1
• The benefits of hardware removal for symptomatic cases are "dramatic and immediate," with pain produced described as "inconsequential" 1
• No complications occurred in the initial case series of hardware removal for symptomatic radiculopathy 1

Addressing the Fusion Status

Hardware Removal Does Not Compromise Fusion

• The patient is now 4+ months post-fusion (surgery 7/1/25, current evaluation 10/30/25), which provides adequate time for early fusion consolidation 2
• Studies demonstrate that implant removal may not be needed for maintaining fusion in thoracolumbar fractures, but when hardware causes symptoms, removal is justified 2
• Radiological and functional outcomes are similar between implant removal and retention groups when fusion has occurred 2

Reinsertion Plan (CPT 22849)

• The surgical plan includes reinsertion of spinal fixation (CPT 22849), indicating the surgeon intends to maintain stability while addressing the symptomatic hardware 1
• This approach allows for repositioning of instrumentation away from the compressed nerve root while maintaining fusion construct integrity 1

Critical Clinical Considerations

Differential Diagnosis Addressed

• No recurrent disc herniation on imaging rules out alternative surgical pathology 3
• The left leg symptoms are "improving slowly," confirming the original pathology was appropriately addressed 1
• The isolated right-sided symptoms that developed postoperatively, combined with EMG findings, point specifically to iatrogenic nerve injury from hardware 1

Timing of Intervention

• Early intervention for symptomatic hardware is preferable to prevent permanent nerve damage from prolonged compression 1
• The patient has already waited nearly 4 months since surgery, providing adequate time to assess for spontaneous improvement 1
• Continued conservative management is unlikely to resolve symptoms caused by mechanical nerve compression from malpositioned hardware 1

Surgical Approach Recommendation

Minimally invasive hardware removal with revision is the appropriate treatment, as it:

• Addresses the symptomatic nerve compression directly 1
• Allows for repositioning of instrumentation away from the L5 nerve root 1
• Maintains fusion construct stability through reinsertion 1
• Minimizes additional surgical morbidity with modern techniques 1

Expected Outcomes

• Resolution of right lower extremity radicular symptoms based on published case series 1
• Minimal postoperative pain and rapid recovery (1-day hospital stay) 1
• Preservation of fusion integrity with revised hardware positioning 2