Cervical Myelopathy: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for EBI Electric Bone Growth Stimulator (HCPCS Code E0748). This patient has a history of cervical myelopathy. She underwent C4-7 anterior cervical discectomy and fusion. Operative findings documented severe central stenosis due to disc osteophyte complex, as well as cervical kyphosis and degenerative disc disease. The patient’s provider recommended an EBI electric bone growth stimulator. Researchers concluded that there was moderate quality evidence supporting the use of post-operative electrical stimulation as an adjunct to spinal fusion surgery. The authors found that patients treated with electrical stimulation have significantly greater rates of successful fusion.

The patient is a 59-year-old female with a history of neck pain “for many years.” She had a C5-6 fusion and achieved “99% relief” until August 2003 when she developed axial pain. The patient had an MRI at that time and was told, “everything looks good.” The patient was treated with bilateral shoulder trigger point injections and her shoulder pain improved, but her neck symptoms continued. The patient was also treated for lower back and right lower extremity pain in early 2006.The patient reportedly developed vertigo and headaches in February 2006, which persisted with radiation to the left scapula, and upper extremity. The symptoms were reported to worsen and an MRI was apparently ordered by another of the patient’s long-term providers due to “concern(ed) about possible complications” in view of the abrupt onset of the patient’s symptoms.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement at C4-C5 and C5-C6. In a prospective, randomized, controlled multicenter investigational device exemption clinical trial comparing cervical total disc replacement compared with anterior cervical discectomy and fusion for treatment of 2-level symptomatic degenerative disc disease, researchers concluded that two level cervical total disc replacement (TDR) was superior to anterior cervical discectomy and fusion (ACDF), and that the differences in clinical effectiveness of TDR versus ACDF became more apparent as treatment increased from one to two levels. The authors further noted that both surgeries had lower rates of second surgery, higher adjacent level disc survivorship, and were effective in alleviating pain relative to baseline.

A 61-year-old male enrollee has requested neck surgery, brand name medications Percocet and Norco, and Carisoprodol and Diazepam 10 mg for treatment of his neck pain. Findings: The physician reviewer found that review of the submitted documentation demonstrates the patient would not benefit from the continued use of Percocet, Norco, Carisoprodol, and Diazepam given the lack of any significant relief to warrant continued use, in addition to the presence of significant risk factors.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for cervical myelopathy was denied, the published record says the denial is worth fighting.