Cervicalgia 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 Percocet. Findings: Guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The guidelines were not intended to provide a hard limit to the prescribing of opioid medications for chronic pain patients. To clarify these issues, the CDC recently announced that providers “should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.” Other guidelines noted that, “continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of s…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for occipital nerve block and/or peripheral nerve block injections.On review of the records, this patient presented with a history of occipital neuralgia and cervicalgia. The patient underwent treatment with occipital nerve block and peripheral nerve block injections. A retrospective review identified four randomized controlled trials that demonstrated trigger point injections were effective in reducing pain scores compared to medical treatment. One study concluded that greater occipital blocks are an effective and safe technique shown to be beneficial in patients with migraine, cluster headache, and cervicogenic headache.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical decompression surgery and cervical laminoplasty. This patient is being treated for spinal stenosis of the cervical region, bicipital tendonitis of the left shoulder, cervical spine radiculopathy, facet arthropathy of the cervical region, and cervicalgia. The patient presented with chronic neck pain with worsening about one year ago. The patient reports numbness and paresthesias in the hands going up to the shoulders. The patient’s physical examination revealed difficulty performing shoulder shrugs due to diffuse tenderness and limited motor strength secondary to whole body pain and tenderness. The patient has requested surgical intervention with cervical decompression surgery and cervical laminoplasty.

The patient has requested authorization and coverage for Electric wheelchair, a new walker or repair of the enrollee’s current walker, handrails for the enrollee’s home, and bathtub bars. The records provided for review support that this patient’s diagnoses include cervicalgia, back pain, and chest pain. The documentation does not reveal that there has been a face-to-face evaluation by a physician or a physical therapist of the patient and home determining that the requested items are appropriate for this patient and her home. The records do not include a thorough mobility evaluation or documentation that the patient is unable to perform usual activities of daily living (ADLs) within the home without a power mobility device. There was no formal gait evaluation revealing that she is unable to ameliorate her mobility deficits with an appropriately fitted walker or cane.

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