Cervical Radiculopathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic interlaminar epidural injection and/or sacroiliac joint injection. With regard to the request for cervical epidural steroid injection, there is medical evidence supporting this treatment modality in specific patients. Medical literature noted that, “repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection.” This patient’s records document chronic neck pain with a diagnosis of cervical radiculopathy and severe degeneration with a C5-6 and C6-7 disc herniation with stenosis. The provider notes that the patient is experiencing neck pain and bilateral upper extremity paresthesias.

Physician 1: The patient is a 38-year old woman who sustained a cervical injury in 1994 as the result of a physical assault. She has had a cervical fusion, left thoracic outlet decompression, and right scalenectomy since the incident. She has chronic pain due to muscle spasms in the neck, shoulders and back. More conservative treatments did not completely resolve her symptoms and she began Botox injections in 2003 and indicates that her symptoms have improved significantly. The patient is requesting coverage for continued treatment with Botox injections. The Health Plan considers the treatment investigational and has denied coverage.A review of the literature fails to confirm the safety and efficacy of Botox injections for pain due to thoracic outlet syndrome or cervical radiculopathy. With regard to this patient, it is not clear that Botox injections are the best treatment alternative.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cervical Artificial Disc Replacement (CPT 22856).Coric and colleagues completed an independent review of a prospective, randomized, controlled multicenter investigational device exemption clinical trial. Their results supported the use of anterior cervical surgery for contiguous 2-level pathology as safe and effective. They concluded that total disc replacement was superior to anterior cervical discectomy and fusion for the treatment of 2-level contiguous pathology at five years. Radcliff and colleagues completed a prospective, randomized, controlled multicenter investigational device exemption clinical trial comparing cervical total disc replacement with anterior cervical discectomy and fusion for treatment of 2-level symptoms degenerative disc disease.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF). In a review by researchers, the authors assert that cervical disc disease includes chronic disc degeneration, stenosis, spondylosis, and disc herniation. The authors noted that these conditions are initially treated conservatively through symptomatic care and that surgery may be indicated when conservative measures fail.

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