Back Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery and reconstruction. According to researchers, reduction mammaplasty is a highly effective procedure for the treatment of symptomatic macromastia. One study investigated whether small-volume resections in reduction mammoplasty produced symptomatic improvement. The authors concluded that “reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments.” In this case, the patient has a history of chronic bilateral thoracic and lumbar pain and symptomatic macromastia. The patient reported back pain, shoulder pain, headaches, postural changes, intertrigo, inability to participate in exercise activities, and poorly fitted clothing.

A 66-year-old male enrollee has requested a CT thorax, CT abdomen, MRI brain and MRI thoracic spine for an evaluation of his upper epigastric discomfort, back pain an headaches. Findings: The physician reviewer found that this patient presented with pleuritic type chest pain and difficulty breathing. The chest x-ray showed no acute disease, and the patient’s symptoms persisted following a trial of antibiotics. These symptoms could be due to infectious or inflammatory disease of the chest, pulmonary embolism or pericarditis. CT scan of the thorax can evaluate for pulmonary embolism/infarct, small areas of infection not visible on chest x-ray and areas of inflammation within the lung and/or pericardium. With a normal chest x-ray and continued symptoms following antibiotic therapy, a CT of the thorax was medically appropriate.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for referrals to head and neck surgery, maxillofacial surgery, chiropractic, cardiology, pulmonology and a bone density test for evaluation of the enrollee’s neck pain, back pain, chest pain, and headaches. Findings: The physician reviewer found that with regard to the request for referral to head and neck surgery and referral to maxillofacial surgery, the records indicate that the patient was previously evaluated by a head and neck surgeon. This evaluation included a history, an examination, an assessment and plan. The provider did not find that the patient was a candidate for any surgical intervention and recommended treatment with corticosteroid nasal spray and salt water nasal spray. Further, the patient had subsequent imaging of the sinuses and nasal septum both with CT and MRI.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tramadol 50 mg, 60 tablets every 30 days.Tramadol is a controlled substance that has opioid agonist activity and also inhibits the re-uptake of serotonin and norepinephrine. Thiels and colleagues conducted a study to determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids. The authors noted that patients receiving tramadol alone had a similar or somewhat greater risk of prolonged opioid use after surgery. Per the authors, “Although all factors related to the safety of a drug must be considered, from the standpoint of opioid dependence, the Drug Enforcement Administration and U.S.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving back pain, then check the rights and deadlines that apply to your plan.