Degenerative Disc Disease 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 artificial disc replacement surgery by anterior approach (CPT code 22857). The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for L4-L5 minimally invasive intradiscal lumbar interbody fusion (MIS-IntraLIF) with L4-5 facetectomies and discectomy, intrafacet and interbody autograft-allograft arthrodesis, and placement of interbody mechanical device. Treatment of low back pain with lumbar fusion, in the absence of instability, trauma, tumor, or fracture is and has been a very common practice although controversy remains in terms of its efficacy, safety, and cost effectiveness. The main question explored in current medical literature is whether lumbar spinal fusion surgery is better than nonoperative management in patients who have already tried and failed long-term exhaustive conservative management.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided. Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness.

Physician 1: The patient is a 43-year-old female with low back and bilateral leg pain. She has had back pain for a number of years with leg pain beginning in 2005. She has been treated with medication, therapy injections and rhizotomy.X-rays performed in January 2006 showed moderate L4-5 disc space narrowing and modest L5-S1 narrowing. There was L4-5 spur formation with no spondylosis. In February 2006 the patient was evaluated for low back and left leg pain to the foot. On examination sensation was grossly intact. Reflexes were symmetrical and active. The patient had a normal gait, more pain with extension and positive left straight leg raise. Strength was 5/5. The provider reported that an MRI showed degenerative disc disease and bulging at L3-4, L4-5 and L5-S1. A discogram in April 2006 revealed L2-3 was not painful. At L3-4 there was concordant pain of 8/10.

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 degenerative disc disease, then check the rights and deadlines that apply to your plan.