Cervical Degenerative Disc Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 46-year-old female with chronic neck pain. The patient has been seen at least twice by a pain specialist. In 1993, the patient received cervical spine x-rays, which showed degenerative disc disease at C6-7, facet degenerative changes at C6-7 and on the left at C4-5. The patient had two prior MRI scans of the cervical spine in 1997 and 2001. The 2001 scan revealed a disc bulge at C4-5 and mild loss of disc height at C5-6 with disc protrusion encroaching on the left of the neuroforamina. In addition, there was loss of disc height at C6-7. A neurological exam performed in April 2002 revealed hypesthesia on the right at C5-6 distribution. The patient has been on significant pain medications such as oxycodone and MS Contin. She continues to experience significant neck pain. The patient’s pain specialist has ordered a follow-up MRI of the cervical spine.

Findings: The physician reviewer found that a patient has requested authorization and coverage for a cervical magnetic resonance imaging (MRI) scan.Conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose post-surgical complications, degenerative disease, spinal stenosis, or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI or computed tomography (CT). According to the American College of Radiology (ACR) Appropriateness Criteria, in a patient with chronic cervical pain with degenerative changes seen on radiographs, an MRI of the cervical spine is usually appropriate as the next imaging study. MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, foraminal stenosis, nerve root compression, and spinal stenosis.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) cervical and lumbar spine. In this case, x-rays of the left wrist/forearm/humerus/elbow were unremarkable. A cervical x-ray showed fusion at C6-C7 and moderate C5-C6 degenerative disc disease. Notes report diagnoses including chronic neck pain, numbness of the fingers, and acute midline low back pain with left-sided sciatica. The patient reported tingling in the left arm along with numbness of the fingers. She reported three weeks of left-sided sciatica.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an artificial disc replacement (C6/C7 level). Findings: The physician reviewer found that the patient who has a history of neck problems. The patient was status post total disc replacement at the C5/6 level. The patient presented for orthopedic evaluation for left sided neck and shoulder pain and left weakness. The patient had been treated with facet injections at the C6/7 and C7/T1 with exponentially increased pain. The patient underwent a left C5 epidural steroid injection with some reduction of pain during the anesthesia phase. The patient reported a difficult time with grip but no difficulty with fine motor skills, no myelopathic gait, no associated falls, and no bowel/bladder incontinence. The patient is on several pain medications.

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 cervical degenerative disc disease, then check the rights and deadlines that apply to your plan.