Is L3-5 fusion medically necessary for a patient with lumbar radiculopathy and significant disc bulges and canal stenosis at L3-4 and L4-5 levels, who has tried conservative therapies for at least 6 weeks?

Medical Necessity Determination for L3-5 Fusion

L3-5 decompression and fusion is NOT medically necessary for this patient based on current evidence, as routine fusion for primary disc herniation with radiculopathy is not supported by guidelines, and the patient does not meet the critical requirement of documented 6 weeks of conservative therapy specifically for lumbar symptoms. 1, 2

Critical Deficiencies in Medical Necessity Criteria

Inadequate Conservative Management Documentation

• The patient has NOT completed 6 weeks of conservative therapy specifically for lumbar radiculopathy. 2
• The physical therapy re-evaluation note from 11/4/2025 (visit #15) documents treatment for both shoulder and low back, with the patient "presenting with new script to include low back pain" and being "s/p R RTC repair." 2
• This indicates the PT was primarily for shoulder rehabilitation, not dedicated lumbar spine treatment. 2
• The CPB criteria explicitly require "at least 6 weeks of conservative therapy" including "active physical therapy (in-person as opposed to home or virtual physical therapy)" specifically directed at the lumbar condition. 2
• Without documented 6 weeks of dedicated lumbar-focused conservative therapy, this case fails to meet basic medical necessity criteria. 2

Absence of Indications for Fusion in Primary Disc Herniation

The American College of Neurosurgery guidelines are clear: routine fusion for primary disc herniation with radiculopathy is NOT recommended. 1, 2

The patient presents with:

• Primary disc herniation at L3-4 and L4-5 (not recurrent herniation) 1
• Radiculopathy without documented spinal instability 1, 2
• No evidence of spondylolisthesis or deformity 1, 2

Fusion is only indicated in specific circumstances that are NOT present in this case: 1, 2

• Preoperative lumbar instability (not documented) 1, 2
• Recurrent disc herniation with chronic axial back pain (this is primary, not recurrent) 1
• Manual laborers with significant preoperative axial low-back pain (occupation not documented as manual labor) 1
• Recurrent disc herniation with associated spinal deformity (not present) 1, 2

Surgeon's Justification Does Not Meet Evidence Standards

The surgeon states: "the patient will need wide decompression that will cause iatrogenic instability at these levels." 2

This justification is problematic: 1, 2

• Iatrogenic instability is only an indication for fusion when it occurs INTRAOPERATIVELY and is documented at the time of surgery, not predicted preoperatively. 2
• The CPB criteria state fusion is appropriate "when performed with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis and there is documented intraoperative iatrogenic instability." 2
• Preoperative planning to perform a "wide decompression" that will "cause" instability suggests the surgical approach itself may be unnecessarily aggressive. 1, 2

What This Patient Actually Needs

Appropriate Conservative Management First

Before ANY surgical intervention, this patient requires: 2

• Documented 6 weeks of dedicated lumbar-focused physical therapy (not combined shoulder/back therapy) 2
• Patient education specific to lumbar radiculopathy 2
• Trial of NSAIDs, acetaminophen, or tricyclic antidepressants 2
• These must be recent (within the past year) 2

If Surgery Becomes Necessary After Adequate Conservative Therapy

Decompression alone (laminectomy without fusion) is the appropriate surgical intervention for this patient: 1, 2

• Multiple studies demonstrate excellent outcomes with decompression alone for primary disc herniation with radiculopathy 1
• The patient has moderate to severe canal stenosis and nerve root compression that would respond to decompression 1
• Adding fusion increases operative time, blood loss, hospital stay, and total cost without proven benefit in this population 1, 2

Common Pitfalls to Avoid

Performing fusion without clear indications increases costs and complications without improving outcomes. 2

• The addition of fusion to discectomy for primary herniation does NOT improve patient outcomes in the general population 1
• Imaging findings of degenerative changes do not necessarily correlate with pain and should not be the sole basis for surgical decision-making 2
• Predicting iatrogenic instability preoperatively is not an accepted indication for fusion. 2

The patient's imaging findings (disc bulges, canal stenosis, foraminal narrowing) are appropriate for decompression surgery, but NOT for fusion. 1, 2

Recommendation

DENY medical necessity for L3-5 fusion. 1, 2

Require: 2

1. Documentation of 6 weeks of dedicated lumbar-focused conservative therapy including active physical therapy, patient education, and appropriate medications 2
2. If surgery remains indicated after adequate conservative management, approve decompression alone (laminectomy/discectomy) without fusion 1, 2
3. Fusion should only be considered if intraoperative instability is documented during the decompression procedure 2