Is a posterior cervical decompression with instrumented fusion medically indicated for a 59-year-old male with a history of Anterior Cervical Discectomy and Fusion (ACDF) C5-7, pseudarthrosis at C6-7, moderate stenosis at C7-T1, and persistent symptoms despite conservative therapy?

Medical Necessity Determination: DENIED - Criteria Not Met

This posterior cervical decompression with instrumented fusion C4-T1 does NOT meet medical necessity criteria due to failure to document nicotine-free status for the required 6-week period with laboratory confirmation before revision surgery for pseudarthrosis. 1, 2

Critical Deficiency: Nicotine Cessation Documentation

The MCG criteria explicitly require that for cervical pseudarthrosis not associated with hardware failure, the patient must be nicotine-free for at least 6 weeks prior to surgery, with lab report (not surgeon summary) showing blood or urinary nicotine levels ≤10 ng/ml or urinary cotinine levels ≤10 ng/ml, drawn within 6 weeks prior to surgery. 2

• The documentation states the patient "quit smoking around [DATE]" but provides no laboratory confirmation of nicotine/cotinine levels 2
• This is an absolute requirement that cannot be waived for pseudarthrosis revision surgery 2
• Nicotine use significantly impairs fusion rates and increases pseudarthrosis risk, making this requirement evidence-based and non-negotiable 1, 3

Levels That DO Meet Criteria

C6-7 Pseudarthrosis (Primary Indication)

• Documented 40% non-union at the lower half of the ACDF construct on CT imaging meets radiographic criteria for symptomatic pseudarthrosis 1, 2
• The patient has persistent neck pain, occipital headaches, and radiculopathy symptoms correlating with the failed fusion 1, 2
• Pseudarthrosis confirmed by radiologist discussion showing lucency extending across C6-7 fusion 1
• Revision of symptomatic pseudarthrosis is recommended because arthrodesis is associated with improved clinical outcome, with posterior approaches showing higher fusion rates (94%) compared to anterior revision (76%) 1

C7-T1 Stenosis

• Moderate bilateral foraminal narrowing at C7-T1 documented on MRI meets the "moderate, moderate to severe, or severe" threshold required by MCG criteria 2
• Minimal anterolisthesis of C7 on T1 with disc flattening provides additional biomechanical indication 2
• Clinical correlation with hand numbness and 4+/5 grip weakness supports neural compression at this level 2

Levels That DO NOT Meet Criteria

C4-5 Level

• Advanced degenerative changes at the right C4-5 facet joint with narrowing of the right neural foramen does NOT meet criteria 2, 4
• The imaging reports describe "narrowing" but do not use the required terminology of "moderate, moderate to severe, or severe" stenosis 4
• Slight anterolisthesis of C4 on C5 is described as "slight" - insufficient to meet instability criteria without flexion-extension radiographs demonstrating pathologic motion 4
• MCG criteria require advanced imaging to indicate stenosis graded as moderate, moderate to severe, or severe - descriptive terms like "narrowing" and "advanced degenerative changes" do not satisfy this requirement 2, 4

C5-6 Level

• Mild bilateral foraminal narrowing at C5-6 explicitly does NOT meet criteria, as MCG excludes "mild or mild to moderate" stenosis 2
• This level is within the prior ACDF construct and shows intact hardware without evidence of pseudarthrosis 2

Conservative Therapy Assessment: PARTIALLY MET

• C7-T1 epidural steroid injection performed on two dates meets injection requirement 2
• TENS therapy and Norco medication documented 2
• Critical deficiency: Documentation states "patient has tried PT and pain management injections without relief" but does not specify when formal physical therapy was performed, duration, or frequency 2
• MCG requires at least 6 weeks of recent (within the past year) active physical therapy with specific documentation 2
• The vague reference to prior therapy without dates or details is insufficient to meet this criterion 2

Surgical Approach Considerations

For revision of anterior pseudarthrosis, posterior approaches demonstrate superior fusion rates (94% vs 76% anterior revision) and better clinical outcomes (88% excellent/good vs 59% anterior revision). 1

• Posterior revision with instrumented fusion is the appropriate surgical approach for C6-7 pseudarthrosis 1
• Extension to C7-T1 for documented moderate stenosis is justified 2
• However, inclusion of C4-5 and C5-6 levels that do not meet severity criteria represents overtreatment and is not supported by guidelines 2, 4

Required Actions Before Approval

Mandatory Requirements:

1. Laboratory documentation of nicotine/cotinine levels ≤10 ng/ml drawn within 6 weeks prior to proposed surgery date 2
2. Detailed documentation of formal physical therapy including dates, duration (minimum 6 weeks), frequency, and specific interventions performed within the past year 2
3. Amended radiology report or additional imaging interpretation for C4-5 using policy-compliant terminology ("moderate, moderate to severe, or severe" stenosis) OR removal of C4-5 from the surgical plan 2, 4

Recommended Modifications:

• Revise surgical plan to C6-T1 posterior cervical decompression with instrumented fusion, removing C4-5 and C5-6 levels that do not meet criteria 2, 4
• Consider flexion-extension radiographs if C4-5 instability is suspected, as static imaging cannot adequately assess segmental instability 4

Clinical Pitfalls to Avoid

• Performing multilevel fusion when only some levels meet severity criteria is not supported by guidelines and increases morbidity without evidence of benefit 2, 4
• Proceeding with pseudarthrosis revision without documented nicotine cessation significantly increases the risk of recurrent non-union 1, 3
• Accepting surgeon summary statements about nicotine cessation without laboratory confirmation does not meet policy requirements 2
• The 59-year-old patient's age and history of multiple prior spine surgeries (3 lumbar, 1 cervical) place him at higher risk for complications, making strict adherence to criteria even more critical 3

Determination

NON-CERTIFICATION with request for:

1. Laboratory nicotine/cotinine levels
2. Detailed physical therapy documentation
3. Either amended imaging reports with severity grading for C4-5 OR revised surgical plan limited to C6-T1

Once these requirements are met, C6-T1 posterior cervical decompression with instrumented fusion would be medically necessary and appropriate. 1, 2