Disc Herniation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Researchers noted that low back pain continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. One study concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. This patient presented on several dates for follow-up of low back pain with left leg radiation. Initially, the patient reported painful radiculopathy with reduced function and activities of daily living. The patient’s range of motion was decreased due to pain and straight leg raise was positive.

Nature of Statutory Criteria/Case Summary: An enrollee has requested laminectomy surgery of the lower back for treatment of the enrollee’s back pain. Findings: The physician reviewer found that the medical literature supports the use of lumbar laminectomy for patients with spinal stenosis who have failed conservative treatment. This patient presents with severe axial low back pain radiating into the left posterior leg to the foot with numbness. The signs and symptoms were consistent with neurogenic claudication. Clinical examination findings correlated with imaging evidence of L1-2, L4-5 and L5-S1 disc herniations with significant central canal stenosis at L1-2 and L5-S1, and reported evidence of nerve root compromise and bilateral foraminal stenosis at L4-5.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested microendoscopic discectomy and related services on an emergent or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

An enrollee has requested authorization and coverage for lumbar fusion-multiple levels: decompression and fusion.Rao and colleagues have found that anterior lumbar interbody fusion (ALIF) is an effective treatment for degenerative disc disease (with and without radiculopathy) or spondylolisthesis. Further studies were recommended, however, to establish the effectiveness of ALIF for scoliosis, failed posterior fusion, and adjacent segment disease. Wang and colleagues have supported the consideration of lumbar fusion for patients with degenerative disc disease and disc herniations with radiculopathy, based on low level evidence when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor.

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