Cervical Stenosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mobi-C two-level artificial cervical disc replacement (codes 22856 and 22858) for treatment of the enrollee’s left upper extremity radiculopathy and weakness. Findings: The physician reviewers found that cervical disc replacement is U.S. Food and Drug Administration (FDA) approved at one or two levels with Mobi-C. The peer-reviewed literature supports one- or two-level cervical disc replacement for specific indications of cervical disc degeneration and myeloradiculoapthy. There is evidence supporting net health outcomes in the presence of well-designed and executed randomized controlled trials with adequate follow-up on two-level cervical disc arthroplasty.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for anterior cervical discectomy and fusion at levels C4 through C7. Magnetic resonance imaging demonstrates stenosis and foraminal narrowing at C4-C5, C5-C6, and C6-C7, findings consistent with the patient’s cervical radiculopathy symptoms.The records indicate persistent symptoms despite conservative treatment, including nonsteroidal anti-inflammatory medications, gabapentin, and epidural steroid injection therapy.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anterior cervical discectomy and fusion (ACDF) at C6-C7. A study concluded that ACDF “is feasible for the treatment of GCDH (Giant cervical disc herniation) disease.” The authors noted that ACDF can be used to safely remove herniated disc fragments, effectively relieve compression of the spinal cord, and improve neurological function. According to another study, ACDF is an effective technique for the treatment of cervical spondylosis. Moreover, one study noted that ACDF can produce a good curative effect for single-level patients whose conservative treatment has been ineffective for more than three months and who are experiencing severe symptoms.

Findings: The physician reviewer found that The patient has requested authorization and coverage for neck surgery (anterior cervical discectomy and fusion (ACDF) C3-C4 and C5-C6). In a prospective, randomized study of five to eight year outcomes of surgical versus nonsurgical treatment in patients with cervical radiculopathy, Engquist and colleagues concluded, “ACDF combined with physiotherapy reduced neck disability and neck pain more effectively than physiotherapy alone.” Current medical literature supports the use of instrumentation during ACDF at the discretion of the surgeon. Yoo and colleagues report that clinical and radiological outcomes of ACDF with titanium, carbon fiber, or polyetheretherketone (PEEK) cages did not appear to be influenced by the chosen synthetic graft.

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