Is anterior cervical discectomy and fusion C6/7 and C7/T1 with spacer medically necessary for a patient with cervical disc degeneration, severe left neuroforaminal stenosis, and moderate to severe right neuroforaminal stenosis?

Medical Necessity Determination for Two-Level ACDF C6/7 and C7/T1

The requested two-level anterior cervical discectomy and fusion at C6/7 and C7/T1 with instrumentation and interbody devices is medically necessary based on severe bilateral neuroforaminal stenosis, objective motor weakness (3/5 left finger strength), failed conservative therapy, and clear radiographic-clinical correlation. 1

Surgical Indication Criteria - All Met

The patient satisfies all established criteria for cervical fusion surgery:

• Neural compression with objective deficits: Severe left and moderate-to-severe right neuroforaminal stenosis at C6-7, plus severe bilateral neuroforaminal stenosis at C7-T1 with documented left paracentral foraminal disc extrusion 1
• Objective motor weakness: 3/5 strength in left finger abductors and flexors represents significant functional impairment that impacts activities of daily living 1
• Failed conservative management: Completed physical therapy course and trial of multimodal medications (naproxen, Flexeril, gabapentin) without adequate relief 1
• Radiographic-clinical correlation: MRI demonstrates severe stenosis at levels corresponding precisely to the patient's left arm weakness and pain distribution 1

Two-Level Fusion Justification

Both C6/7 and C7/T1 require surgical intervention:

• C6-7 pathology: Broad-based disc osteophyte complex with bilateral uncovertebral hypertrophy causing severe left neuroforaminal stenosis and moderate-to-severe right neuroforaminal stenosis directly correlates with left arm weakness 1
• C7-T1 pathology: Left paracentral foraminal disc extrusion with cranial and caudal migration causing moderate central stenosis and severe bilateral neuroforaminal stenosis (left > right) represents a distinct compressive lesion requiring separate decompression 1
• Both levels meet severity threshold: Guidelines specify that moderate-to-severe or severe stenosis (not mild or mild-to-moderate) justifies surgical intervention, and both levels clearly meet this standard 1

Instrumentation Medical Necessity (CPT 22845)

Anterior cervical plating is medically necessary for this two-level construct:

• Improved fusion rates: For two-level disease, anterior plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% 1
• Maintains cervical lordosis: Instrumentation prevents graft subsidence and maintains proper cervical alignment, which is critical for foraminal decompression 1
• Greater stability: Multilevel fusions require instrumentation to provide adequate stability and improved outcomes 1

Interbody Device Medical Necessity (CPT 22853 x2)

Synthetic interbody cages/spacers are appropriate for this case:

• Immediate structural support: Interbody devices maintain disc height and provide immediate load-bearing capacity, which is critical for foraminal decompression 1
• Standard of care: Synthetic cages are medically necessary for cervical fusion in patients meeting criteria for ACDF 1
• Two devices required: One interbody device is needed at each fusion level (C6/7 and C7/T1) 2, 3

Expected Surgical Outcomes

The evidence strongly supports excellent outcomes for this patient:

• Arm pain relief: 80-90% success rate for relief of radicular arm pain with ACDF 1
• Functional improvement: 90.9% functional improvement following surgical intervention for cervical radiculopathy with motor deficits 1
• Rapid symptom relief: ACDF provides relief within 3-4 months compared to continued conservative management 1
• Motor recovery: Long-term improvements in motor function are maintained following anterior decompression 1

Inpatient Level of Care Determination

Outpatient surgery is the appropriate level of care for this two-level ACDF procedure. While the insurance policy notes "no inpatient GLOS for this case," this actually supports outpatient status:

• Standard practice: Two-level ACDF is routinely performed as an outpatient procedure with excellent safety profiles 3
• Patient factors: The 45-year-old patient has no documented comorbidities requiring inpatient monitoring 1
• Procedure complexity: Two-level anterior cervical fusion without posterior supplementation does not require inpatient admission 3
• Recovery expectations: Patients typically achieve adequate pain control and mobility for same-day or 23-hour observation discharge 3

Critical Pitfalls to Avoid

• Do not operate on levels with only mild stenosis: The policy explicitly excludes mild or mild-to-moderate stenosis from surgical criteria; both C6/7 and C7/T1 clearly meet the moderate-to-severe or severe threshold 1
• Do not skip instrumentation on two-level constructs: The dramatic reduction in pseudarthrosis rates (4.8% to 0.7%) with plating makes instrumentation essential for two-level disease 1
• Do not attribute symptoms to wrong levels: The patient has multilevel disease (C3-4, C4-5, C5-6 also show pathology), but only C6/7 and C7/T1 demonstrate severe stenosis correlating with the objective motor deficits 1

Addressing the C7/T1 Level Specifically

The C7/T1 level warrants particular attention:

• Distinct pathology: The left paracentral foraminal disc extrusion with fragment migration represents a different pathological process than the C6-7 spondylotic changes 1
• Severe bilateral stenosis: C7-T1 demonstrates severe bilateral neuroforaminal stenosis, meeting surgical criteria independently 1
• Technical feasibility: While C7-T1 ACDF is less common than more cephalad levels, it is well-established and safe when performed via anterior approach 4