AllMed Webinar Updates Health Plans On The Latest Standards Of Medical Necessity For Lumbar Fusion

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AllMed webinar provides in-depth review of the latest standards of medical necessity for Lumbar Fusion

AllMed Healthcare Management
The indications for lumbar fusion are controversial, especially when it is used to treat patients with spinal stenosis with or without spondylolisthesis, recurrent disc herniation, and degenerative disc disease.

Although a number of conditions of the spine benefit from lumbar fusion, some off-label uses are associated with inconsistent outcomes and significant potential risks and complications. In addition, continual technological developments complicate the process of establishing evidence-based criteria for practice guidelines and reimbursement policies. During a recent AllMed webinar, Dr. Michael Dorsen, a board certified in neurosurgeon, discussed the latest issues related to determining medical necessity of lumbar fusion.

In his presentation, Dr. Dorsen began with an overview of the lumbar anatomy, providing a closer look at the components of the lumbar spine. He described the intervertebral discs, which are gel-like cushions found between each vertebra, and the facet joints, which link the vertebrae together and help make the spine flexible. The spinal cord descends from the brain through the spinal canal formed by the vertebrae, ending in between the first and second lumbar vertebrae. Below that, a group of nerves called the cauda equina travels through the spinal canal and branches off to various parts in the lower half of the body.

Dr. Dorsen emphasized the importance of the initial evaluation of patients with low back pain to rule out potentially serious conditions, such as cauda equina syndrome. Conservative therapy is generally not recommended in the presence of progressive neurological deficits, when spinal fracture or dislocation is unstable, or for progressive spinal deformity. Patients without these conditions are initially managed with conservative therapy, which may include, but is not limited to, avoidance of activities, chiropractic manipulation, bed rest, low-impact exercise, and/or pharmacotherapy. According to Dr. Dorsen, there is currently no consensus regarding the optimal duration for conservative treatment prior to surgical intervention for low back pain. He added that recommendations range from at least 3 months to greater than 1 year.

There are two different methods of spinal fusion. Bone can be taken from the patient’s pelvic bone (autograft) or from a bone bank (allograft), and used to make a bridge between vertebrae that are next to each other; this bone graft helps new bone grow. Another option is to use metal implants to hold the vertebrae together until new bone grows between them. Dr. Dorsen listed the potential complications associated with spinal fusion, which include infection, urinary problems, pseudoarthrosis, and blood clots. He noted that some patients may require additional surgery to deal with these problems. One of the most significant risks associated with spinal fusion is adjacent segment disease (ASD), which occurs when the spinal discs either above or below the fusion wear out and become extremely painful. Patients with ASD require re-fusion of the spine to include the newly affected areas.

The indications for lumbar fusion are controversial, especially when it is used to treat patients with spinal stenosis with or without spondylolisthesis, recurrent disc herniation, and degenerative disc disease. Dr. Dorsen reviewed a number of less controversial indications for lumbar fusion, including emergency situations, trauma, revisions, tumor, infection, and congenital structural issues. He also talked about a number of relative contraindications for lumbar fusion, and stated that initial laminectomy/discectomy related to unilateral compression of a lumbar nerve root is an absolute contraindication for lumbar fusion.

The North American Spine Society has developed recommendations that describe specific criteria for the use of lumbar fusion to treat infection, tumor, traumatic injuries, deformity (e.g., scoliosis), stenosis, disc herniations, synovial facet cysts, discogenic low back pain, and pseudoarthrosis. According to guidelines developed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, lumbar fusion is recommended for patients whose low back pain is refractory to conservative treatment, such as physical therapy or other non-operative measures, and is due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis. Dr. Dorsen added that the organizations do not recommend lumbar fusion for: disc herniation in the absence of instability or spondylolisthesis; stenosis in the absence of instability, foraminal stenosis, or spondylolisthesis; discogenic low back pain that does not meet the recommended criteria; and routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. Lumbar fusion is also not recommended in the absence of deformity or instability.

As data continue to emerge, external independent medical review by an independent review organization can help facilitate safe and effective use of lumbar fusion, which requires an in-depth understanding of the evaluation and treatment of spine conditions so that treatment can be individualized for each patient.

The presentation can be found here - Indications for Lumbar Fusion: Establishing Standards for Medical Necessity

About AllMed
AllMed Healthcare Management provides physician review outsourcing solutions to leading health plans, medical management organizations, TPAs and integrated health systems, nationwide. AllMed offers MedReview(sm), MedCert(sm), and MedDirector(sm) staffing services that cover initial pre-authorizations and both internal and external appeals, drawing on a panel of over 400 board-certified specialists in all areas of medicine. Services are deployed through PeerPoint(R), AllMed's state-of-the-art medical review portal. For more information on how AllMed can help your organization improve the quality and integrity of healthcare, contact us today at info(at)allmedmd(dot)com, or visit us at

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Kiki Grant
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