Is anterior cervical discectomy and fusion with pedicle screw, cage, allograft (bone graft), and autograft (bone graft) medically indicated for a patient with persistent neck pain and stiffness, minimal upper extremity pain, and cervical disc degeneration, who has not met the Milliman Care Guidelines (MCG) criteria for cervical spinal fusion?

This Anterior Cervical Discectomy and Fusion is NOT Medically Indicated

This patient does not meet medical necessity criteria for ACDF because there are no objective neurologic deficits documented on examination, which is an absolute requirement for surgical intervention according to major neurosurgical guidelines. 1

Critical Missing Criteria for Surgical Indication

The patient fails to meet fundamental requirements established by the American Association of Neurological Surgeons and American College of Neurosurgery:

• No documented motor weakness in myotomal distribution (e.g., C6 weakness with elbow flexion/wrist extension deficit) 1
• No documented sensory loss in dermatomal distribution corresponding to the affected nerve root 1
• No reflex changes (such as diminished biceps reflex for C5-C6 pathology) 1
• Minimal or no upper extremity pain - the predominant symptom is neck pain alone, which is insufficient indication for fusion surgery 1, 2

Why Imaging Findings Alone Do Not Justify Surgery

The MRI findings of "moderate bilateral neuroforaminal stenosis C5-C6" and "mild central canal stenosis C5-6" are extremely common in asymptomatic individuals - up to 60% of asymptomatic adults over age 40 have disc degeneration 1. The critical principle is that imaging abnormalities must correlate with objective clinical findings before proceeding to surgery 1, 2.

The American College of Neurosurgery explicitly states that ACDF requires "moderate to severe central/lateral recess or foraminal stenosis" with "nerve root/spinal cord compression at levels corresponding with clinical findings" 2. This patient has only "moderate" stenosis without corresponding clinical deficits.

Conservative Management Success Rate

75-90% of patients with acute cervical radiculopathy improve with conservative management 1, 2. While this patient has completed 6 weeks of conservative treatment, the absence of radicular symptoms or objective deficits indicates the current presentation is axial neck pain from degenerative disc disease - a condition that does not require fusion surgery 1.

Specific Hardware Components Are Inappropriate

Pedicle screws (CPT 22845) are NOT used in anterior cervical fusion procedures - they are reserved for lumbar spine or posterior cervical approaches 1. Anterior cervical instrumentation utilizes plate and screw constructs that engage the vertebral body, not pedicle screws 1. This represents a fundamental technical error in the surgical plan.

The proposed use of both allograft (20930) and autograft (20936) with cage (22853) is technically appropriate for ACDF when indicated 3, but the underlying procedure itself lacks medical necessity.

Recommended Clinical Course Instead of Surgery

Continue structured conservative management:

• Structured physical therapy focusing on cervical strengthening and flexibility exercises 1, 2
• Optimize pharmacologic management with scheduled NSAIDs (if not contraindicated) rather than as-needed dosing 1, 2
• Consider cervical epidural steroid injection only if radicular symptoms develop 2
• Serial neurologic examinations to monitor for development of objective deficits that would change the indication 1

Common Pitfall Being Made Here

The surgical plan conflates axial neck pain from degenerative disc disease with radiculopathy or myelopathy requiring decompression. The stated goal to "remove degenerative disc causing nerve compression" is not supported by the clinical examination showing no neurologic deficits 1. The goal to "prevent progression of neurologic symptoms" is not appropriate when no neurologic symptoms currently exist 1.

Algorithm for When ACDF Would Be Indicated

Surgery becomes medically necessary when ALL of the following are present:

1. Objective motor weakness in specific myotomal distribution 1, 2
2. Dermatomal sensory loss corresponding to affected nerve root 1, 2
3. Reflex changes at the affected level 1
4. Imaging showing moderate-to-severe or severe stenosis correlating with clinical level 1, 2
5. Failure of at least 6 weeks of conservative management including physical therapy, NSAIDs, and consideration of epidural steroid injection 1, 2
6. Documentation of impact on activities of daily living 2

If no objective deficits are present → Continue conservative management 1

Evidence Quality Supporting This Recommendation

This recommendation against surgery is based on high-quality guideline evidence from the American Association of Neurological Surgeons and American College of Neurosurgery 1, 2. The 2025 guideline synthesis explicitly addresses this clinical scenario and provides clear criteria that this patient does not meet 1.