Cervical Spinal Cord Injury: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital services provided for treatment of the enrollee’s acute cervical spinal cord injury. Findings: The physician reviewer found that the records indicate that patient had a lesion on imaging concerning for a possible inflammatory versus neoplastic process. There was a history of the patient sustaining injury from a fall. After being observed, evaluated and treated in the hospital, the patient was ready for transfer to a rehabilitation facility, but was not reasonably safe for community re-entry given his complex baseline functional impairments, and his history of multiple falls. His newly-acquired deconditioning administrative days were appropriate while attempting to procure a bed for transfer to a skilled nursing facility.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an RT300 functional neurostimulator electrical stimulator (NMES). The records indicate that this patient sustained a cervical spinal cord injury (SCI) with paralysis of her upper and lower extremities. Patients with SCI are at increased risk for osteoporosis, muscle atrophy and spasticity, pneumonia, and skin breakdown. Given their impaired ability to move and inability to voluntarily exercise, SCI patients are also at risk for the development of cardiometabolic disease. Current medical literature supports the use of functional NMES in patients with SCI to improve bone demineralization.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 Functional Electrical Stimulating (FES) Therapy System.Findings: Two out of three physician reviewers found that RT300 Functional Electrical Stimulating (FES) Therapy System is not likely to be more beneficial for the enrollee than any available standard therapy.The RT300 FES Therapy System provides passive exercise in individuals with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. The data from the medical literature, however, has not demonstrated that use of this device improves function or health outcomes in a clinically significant manner for persons with spinal cord pathology.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME) RT300 functional electrical stimulation (FES) therapy system. Findings: The physician reviewer found that records provided for review document that this patient sustained a traumatic injury to her cervical spinal cord. The patient has partial residual use of her upper limbs. She has declined to use a power wheelchair and she is using a manual wheelchair for her mobility. The mainstay of long-term management in this clinical setting focuses on surveillance and preventive clinical care related to the respiratory system, pressure injury, neurogenic bladder and bowel, tone issues, and monitoring for complications.

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 spinal cord injury was denied, the published record says the denial is worth fighting.