Cervical Spondylosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with cervical intervertebral disc degeneration, cervical spondylosis, cervical radiculopathy, lumbar facet arthritis, and myofascial muscle pain. The provider noted that Suboxone is not appropriate for the patient’s condition and that the purpose of the Belbuca is to provide longer lasting baseline pain relief without drastically increasing her daily opioid morphine equivalent daily dose (MEDD) and to reduce the use of hydrocodone for breakthrough pain. The provider noted that Belbuca is being added to the patient’s current regime of Vicodin to provide better pain control and to prevent further escalation of her opioid MEDD. The patient has been treated with cervical and lumbar epidural steroid injections and cervical facet joint blocks.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for an MRI of the cervical spine. The enrollee has diagnoses of immune thrombocytopenic purpura (ITP) and immunoglobulin A (IgA) deficiency. The enrollee’s medical history includes Klippel-Feil syndrome, cervicalgia, spondylosis of the cervical region, fibromyalgia and scoliosis. At an earlier office visit, the enrollee reported neck pain radiating to his shoulders, with dizziness, and with weakness to his hands, which caused him to drop objects. The progress note from the visit indicated the enrollee would require a C 5-6 fusion in the future. At a recent office visit, the enrollee reported several months of frequent episodes of neck pain; especially if he tipped his head backwards. This led to intermittent dizziness.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cervical artificial disc replacement (C5-6 and C6-7 with the Simplify implant). This patient’s treatment plan includes C5-6 and C6-7 artificial disc replacement with the Simplify implant. The U.S. Food and Drug Administration (FDA) notes that Simplify indications for use include that the patient should have failed at least six weeks of nonoperative treatment or demonstrated progressive signs or symptoms despite non-operative treatment prior to implantation.

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