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

Where the denial was overturned

Physician 1This patient is a 48-year-old woman with a long history of cervical pain. The patient has had multiple cervical surgeries and has not responded to conservative treatment. Apparently, the patient has been treated with Botox in the past and wishes to continue to receive Botox injections. The Health Plan has denied authorization for Botox therapy indicating it is considered investigational for treatment of the patient’s diagnosis.Review of current medical literature fails to confirm the efficacy of Botox in the treatment of the patient’s medical condition. Botox therapy for chronic cervical pain, myofascial pain, and failed neck syndrome has unproven efficacy in case-controlled, randomized, peer-reviewed literature. Thus, there is no scientific evidence to demonstrate that Botox is likely to be of greater benefit to this patient than conservative therapies.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical artificial disc replacement, single level. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s cervical pain.Findings: There is sufficient support in the medical literature for the requested services in this clinical setting. Cervical total disc replacement at one or two levels, anterior cervical discectomy and fusion, as well as hybrid surgery with a combination of the two, significantly improve general and disease specific measures compared with baseline.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for carisoprodol (Soma) 100 tablets per 30 days for treatment of the enrollee’s chronic cervical and lower back pain.Findings: The physician reviewer found that Based on the documentation submitted for review, the medical necessity for the requested medication has not been established. Current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Additionally, the medical literature indicates that Soma is a muscle relaxant with more addictive and abusive properties than opioids. Soma is a centrally acting muscle relaxant, associated with a high risk of dependence and tolerance. Long term administration is not recommended.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck and/or back. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic cervical or neck pain, the initial recommended imaging is radiographs. If the pain does not resolve despite conservative management, including physical therapy and optimal medical management, then an MRI may be indicated to evaluate for disc or neurologic abnormality. In this case, there is no evidence of “red flag” symptoms or radiculopathy. The documentation provided does not indicate that radiographs were performed. There is a lack of documentation of physical therapy. Therefore, an MRI of the neck is not indicated at this time.

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 pain was denied, the published record says the denial is worth fighting.