Chronic Low Back Pain 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 the Intracept procedure (thermal destruction of intraosseous nerve, inclusive of all imaging guidance, first two vertebral bodies, lumbar or sacral). In a randomized control trial evaluating the effectiveness of intraosseous radiofrequency ablation of the basivertebral nerve to standard treatment of chronic low back pain in a specific subgroup of patients suspected to have vertebrogenic related symptomatology, researchers found clear statistical superiority for all primary and secondary patient-reported outcome measures in the radiofrequency ablation arm compared with the standard care arm. The authors noted statistically significant improvements in the Oswestry Disability Index (ODI) scores and visual analogue scores (VAS) in the treatment arm compared to the arm receiving standard care.

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for methadone 10 mg five pills per day. The Health Plan has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollee’s chronic low back pain.The records indicate that this patient is being treated for chronic non-malignant pain. In terms of the patient’s medications, opioid medication can be considered as part of the standard of care when treating patients with chronic non-malignant pain. Concern for opioid misuse can result in undertreatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. The analgesic options for patients with chronic pain have steadily declined.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Intracept procedure at L4-L5 and L5-S1. The U.S. Food and Drug Administration (FDA) approves the use of the Intracept Intraosseous Nerve Ablation System in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain that has not responded to at least six months of conservative care, and is also accompanied by features consistent with type 1 or type 2 Modic changes on magnetic resonance imaging (MRI), such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals, and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signal…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) red light therapy machine for home use, (2) ultrasound machine for home use, and (3) cold therapy unit for home use. There is limited evidence in current medical literature supporting the use of red-light therapy, also referred to as low-level laser therapy (LLLT). Childress and Beutler report regarding the management of chronic tendon injuries, “Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.” However, Baktir and colleagues report regarding the short-term effectiveness of LLLT, “LLLT p…

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 chronic low back pain, then check the rights and deadlines that apply to your plan.