Chronic Neck 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 magnetic resonance imaging of the spine (MRI). Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Over the years, the American College of Radiology (ACR) has established appropriateness guidelines, directing appropriate evaluation of various common conditions. In 1998, an Appropriateness Criteria was established for chronic neck pain. This guideline criteria was subsequently reviewed in 2013. There are clear variations as to the clinical presentation of chronic neck pain. This patient’s presentation fits within one of the criteria guideline parameters. The variant that best describes this patient is either “Chronic neck pain, radiographs normal.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for implantation of a SPRINT peripheral nerve stimulation (PNS) system. A recent study looked retrospectively at patients with multiple chronic pain conditions and concluded that, “PNS has been shown to be safe and effective in treating chronic pain of multiple sites with sustained pain relief for up to 24 months.” Similarly, several other studies have evaluated PNS for other chronic conditions and found a significant improvement in pain scores. With respect to the evidence surrounding PNS for chronic low back pain, one study found that 73% of patients reported over 30% reduction in pain intensity after two months of PNS treatment.

Where the denial was upheld

Findings: The physician reviewer found that the patient requested authorization and coverage for Norco. The Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy prescribing state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy”. Further, the CDC advised that clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids so long as the benefits do not outweigh the risks of continued opioid therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco.Centers for Disease Control and Prevention (CDC) guidelines for the prescribing of opioids for chronic pain state that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. The guidelines state that clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

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