Cervical Disc Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery on the neck.Findings: Two of the three physician reviewers found that the medical evidence supports the requested services in this clinical setting. There are significant benefits documented in the literature with respect to total disc replacement which results in improved general and disease-specific outcome measures and a lower rate of reoperation in the two-level disc replacement patients versus two-level anterior cervical discectomy and fusion control patients. With regards to the long-term results of cervical total disc replacement, there are significant benefits over the conventional multilevel anterior cervical discectomy and fusion.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial disc replacement at C5-6 with Secure-C device. Findings: The physician reviewers found that currently, there are adequate data to support the safety and effectiveness of the Secure-C artificial disc in well selected patients. Studies noted that the Secure-C artificial disc is U.S. Food and Drug Administration (FDA) approved and shows superiority in overall success in single level use. For treating symptomatic cervical disc disease, cervical disc arthroplasty is superior to anterior cervical discectomy and fusion in terms of overall, neck disability index, and neurological success. Furthermore, cervical disc arthroplasty is superior in terms of patient satisfaction, range of motion at the operative level, and secondary surgical procedures rate.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Mobi-C two-level cervical total disc replacement procedure for treatment of her medical condition. Findings: Three physician reviewers found that upon review of the submitted documentation there is inadequate support for two-level cervical disc replacement (arthroplasty) in this case. There are alternative approaches that are likely to avoid potential complications of re-operation and would avoid the potential complications of double-level cervical total disc arthroplasty. In a study by researchers, pooled data from multiple sources were analyzed with an incidence of heterotopic ossification of 44.6% at 12 months after total disc arthroplasty and 58.2% at 24 months. The authors concluding that cervical total disc arthroplasty should be performed cautiously.

A 50-year-old male has requested Oxycontin 40mg tablet (#60), twice per day for treatment of his cervical disc disease. Findings: The physician reviewer found that based on review of the available records, the requested Oxycontin is not medically necessary for treatment of this patient’s medical condition. Such narcotics and at the doses prescribed to the patient is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic neck and wrist pain which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain (Fishman).

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