Is a two-level cervical discectomy and fusion at C4-5 and C5-6 with bone marrow aspiration (BMA) medically necessary for a physical therapist with a history of persistent neck pain and bilateral upper extremity radiation, who has undergone various treatments including physical therapy, epidural steroid injections (ESI), and transforaminal epidural steroid injections (TF ESI) with minimal relief?

Medical Necessity Determination for C4-5 and C5-6 ACDF with Bone Marrow Aspiration

The proposed two-level cervical discectomy and fusion at C4-5 and C5-6 is NOT medically necessary because the imaging demonstrates only mild spinal canal stenosis and mild-to-moderate neuroforaminal narrowing, which fails to meet the required threshold of moderate, moderate-to-severe, or severe stenosis needed to justify fusion surgery. 1

Critical Imaging Deficiency

The fundamental barrier to approval is the severity grading documented on imaging:

• The CT scan shows only "mild spinal canal stenosis" at both C4-5 and C5-6, with "mild-to-moderate" neuroforaminal narrowing 1
• The payer's criteria explicitly require "moderate, moderate to severe or severe" stenosis—not "mild or mild to moderate"—at levels corresponding with clinical findings 1
• Descriptive terms like "encroachment" or "impingement" do not satisfy the specific severity grading requirements 1

This represents a documentation issue rather than necessarily a clinical appropriateness issue. The imaging terminology must be upgraded to policy-compliant language before resubmission can be considered 1.

Bone Marrow Aspiration: Not Medically Necessary

The addition of bone marrow aspiration is unproven and not medically necessary for this indication:

• The payer explicitly considers bone marrow aspirate "unproven for all other orthopedic applications including...as an adjunct to spinal fusion because there is insufficient evidence to support its use for these indications"
• While one retrospective study showed BMA may enhance fusion rates when combined with collagen-hydroxyapatite/PEEK constructs (76.2% vs 75.3% fusion, with faster time to fusion), this represents Class III evidence at best 2
• Standard interbody grafting techniques using autograft, allograft, or titanium/PEEK cages without BMA achieve 90-100% fusion rates for 1-2 level ACDF 3, 4
• Interestingly, one study paradoxically found that lower frequencies of mesenchymal stem cells in bone marrow correlated with better fusion outcomes, challenging the proposed mechanism for BMA efficacy 5

The evidence does not support routine BMA use, and payer policy explicitly excludes coverage for this adjunct.

Conservative Management: Adequately Completed

The patient has appropriately exhausted conservative options:

• Multiple years of consistent physical therapy with no symptom relief
• Serial epidural steroid injections at multiple levels (C3-4, C4-5, C5-6) with minimal and transient benefit (maximum 50-75% relief at C4-5, lasting only briefly)
• Rhizotomy procedures performed with no significant or lasting relief
• Pain management optimization attempted

This extensive conservative trial exceeds typical requirements and would satisfy medical necessity criteria if imaging severity thresholds were met 6, 7.

Clinical-Radiographic Correlation Present

Despite the imaging severity issue, the clinical presentation does correlate anatomically:

• Bilateral upper extremity radiculopathy with numbness/tingling in fingertips suggests multilevel nerve root compression 6
• Pain radiation to shoulders and deltoids corresponds to C4-5 and C5-6 nerve root distributions
• The patient's occupation as a physical therapist creates significant functional impairment
• Symptoms began after motor vehicle accident and have progressively worsened

However, clinical symptoms alone cannot override the imaging severity requirements established in the payer's policy 1.

Recommended Path Forward

Request amended radiology interpretation or additional imaging to specifically address:

1. Explicit severity grading of stenosis using the terms "moderate," "moderate-to-severe," or "severe" rather than "mild" 1
2. Direct documentation of nerve root compression at C4-5 and C5-6 levels, not just "narrowing" 1
3. Consider CT myelography if MRI terminology remains ambiguous, as this may provide clearer documentation of compression severity 1

Additional Considerations

• The CT scan notes "minimal grade 1 degenerative anterolisthesis" at C3-4 and C4-5, but this alone does not constitute instability requiring fusion unless documented on flexion-extension radiographs 1
• For 1-2 level cervical disc disease, ACDF with anterior plating is recommended to reduce pseudarthrosis risk and improve outcomes 3, 6
• If imaging can be upgraded to show moderate-to-severe pathology, ACDF at C4-5 and C5-6 would be appropriate, achieving 80-90% success rates for arm pain relief and 90.9% functional improvement 6, 7
• The severe facet arthropathy at C3-4 noted on imaging may become symptomatic in the future given the biomechanical stress transfer that occurs with lower cervical fusion 8

Common Pitfalls to Avoid

• Do not proceed with surgery based solely on clinical symptoms when imaging severity criteria are not met—this will result in denial 1
• Do not add bone marrow aspiration to the surgical plan—it is explicitly excluded from coverage and lacks sufficient evidence 2
• Ensure any resubmission includes policy-compliant imaging terminology with explicit severity grading 1

Final Recommendation: Non-certification of all requested codes (ACDF at C4-5 and C5-6, bone marrow aspiration) with request for clarified imaging documentation before resubmission.