Is an anterior cervical discectomy and fusion (ACDF) with pedicle screw, cage, allograft (bone graft substitute), and autograft (patient's own bone graft) indicated for a patient with cervical spondylosis and radiculopathy who does not meet the Milliman Care Guidelines (MCG) criteria for cervical spinal fusion?

Medical Necessity Denial Recommended for Proposed ACDF Procedure

This case does not meet medical necessity criteria for anterior cervical discectomy and fusion, and the proposed hardware configuration contains a fundamental technical error that further supports denial. 1

Critical Deficiencies Preventing Authorization

Absence of Objective Neurologic Deficits

The patient presents with "persistent neck pain and stiffness" with "minimal or no upper extremity pain" and critically, "no neurologic deficit noted on exam." 1 This represents a fundamental contraindication to surgical intervention. The American Association of Neurological Surgeons requires documentation of objective radiculopathy with motor weakness, sensory loss, or reflex changes corresponding to the affected level before surgery is indicated. 1

• Without demonstrable motor weakness in myotomal distribution (e.g., C6 weakness with elbow flexion/wrist extension deficit), diminished reflexes (biceps reflex for C5-C6 pathology), or dermatomal sensory loss, surgery cannot be justified. 1
• The absence of upper extremity radicular symptoms further undermines the surgical indication, as ACDF is primarily indicated for radiculopathy or myelopathy, not axial neck pain alone. 2

Inadequate Conservative Management Trial

While the patient completed 6 weeks of physician-directed physical therapy and medication trials, critical conservative measures were not attempted:

• No cervical epidural steroid injection was performed, which the American College of Surgeons recommends as part of comprehensive conservative management before considering ACDF. 3
• The American College of Neurosurgery emphasizes that 90% of acute cervical radiculopathy patients improve with conservative management, and surgery should be reserved for persistent symptoms despite adequate conservative therapy. 1

Imaging-Clinical Mismatch

The MRI demonstrates "moderate bilateral neuroforaminal canal stenosis C5-C6, mild central canal stenosis C5-6," but these findings do not correlate with objective clinical deficits:

• MRI abnormalities are extremely common in asymptomatic individuals—up to 60% of asymptomatic adults over age 40 have disc degeneration. 1
• Guidelines require moderate-to-severe or severe stenosis with clinical correlation to justify surgical intervention. 1
• The patient's imaging shows only moderate stenosis without corresponding neurologic compromise. 1

Fundamental Technical Error in Proposed Hardware

Pedicle Screws Are Not Used in Anterior Cervical Procedures

The inclusion of pedicle screws (CPT 22845) in this anterior cervical procedure represents a critical technical error. 1, 3

• Pedicle screws are reserved for lumbar spine or posterior cervical approaches, not anterior cervical fusion procedures. 1
• Anterior cervical instrumentation utilizes plate and screw constructs that engage the vertebral body, not pedicle screws. 1
• The use of pedicle screws in anterior cervical procedures is not standard of care and lacks supporting evidence. 3

Excessive and Redundant Grafting Strategy

The simultaneous use of cage (22853), allograft (20930), and autograft (20936) represents potentially excessive grafting:

• Evidence demonstrates that single grafting strategies achieve comparable fusion rates without the need for multiple graft types. 3
• For single-level ACDF, either cage alone or autograft alone achieves fusion rates of 83-98%. 3
• The North American Spine Society recommends that for single or double-level ACDF, either cage alone or autograft alone is sufficient. 3
• Autograft harvest causes donor site complications in up to 22% of patients, including persistent hip pain at 1 year, without providing superior fusion rates in 1-level procedures. 3

Clinical Decision-Making Algorithm for This Case

Step 1: Assess for Objective Neurologic Deficits

• Current status: FAILED - No motor weakness, sensory loss, or reflex changes documented. 1
• Required action: Continue conservative management. 1

Step 2: Verify Adequate Conservative Management

• Current status: INCOMPLETE - No epidural steroid injection attempted. 3
• Required action: Optimize non-surgical treatment before reconsidering surgery. 1, 3

Step 3: Confirm Imaging-Clinical Correlation

• Current status: FAILED - Imaging abnormalities without corresponding clinical deficits. 1
• Required action: Clinical findings must match imaging severity. 1

Step 4: Document Functional Impairment

• Current status: INSUFFICIENT - No quantification of functional impairment or impact on activities of daily living documented. 3
• Required action: Medical necessity requires documented symptoms that significantly impact activities of daily living or sleep. 3

Recommended Clinical Course Instead of Surgery

Optimize Conservative Management

• Continue structured physical therapy focusing on cervical strengthening and flexibility exercises, with emphasis on postural training and ergonomic modifications. 1
• Optimize pharmacologic management with scheduled NSAIDs (if not contraindicated) rather than as-needed dosing to maintain therapeutic levels. 1
• Consider cervical epidural steroid injection for symptom management, which should be attempted before surgical consideration. 1, 3

Establish Clear Surgical Thresholds

Surgery becomes medically necessary only when patients demonstrate:

• Progressive neurologic deficits with objective motor, sensory, or reflex changes. 1, 3
• Documented cord compression with corresponding clinical signs (myelopathic symptoms such as gait instability, hand clumsiness, or hyperreflexia). 3
• Failure of comprehensive conservative management including epidural injections over an adequate trial period. 3

Common Pitfalls to Avoid

Do Not Operate Based on Imaging Alone

The 75-90% success rate with conservative management mandates an adequate trial before surgery. 1 Always correlate imaging with objective clinical findings before proceeding. 1

Do Not Confuse Axial Neck Pain with Surgical Indications

ACDF is primarily indicated for radiculopathy or myelopathy, not isolated axial neck pain. 2 There is conflicting Class II evidence as to whether ACDF relieves overall neck pain. 2

Recognize When Hardware Is Inappropriate

Even when ACDF is indicated, the proposed hardware configuration contains errors that would require correction before authorization. 1, 3

Evidence Quality Supporting This Denial

This recommendation is based on high-quality guideline evidence from the American Association of Neurological Surgeons and American College of Neurosurgery, synthesized in recent (2025) guideline summaries. 1, 3 The evidence consistently demonstrates that surgery without objective neurologic deficits leads to poor outcomes and exposes patients to unnecessary surgical risks including dysphagia, recurrent laryngeal nerve injury, pseudarthrosis, and adjacent segment degeneration. 2, 4, 5