Disc Inflam Pain Oth Dorsalgia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar epidural steroid injection. In this case, the patient has reported significant low back pain. Magnetic resonance imaging (MRI) of the patient’s lumbar spine shows impression of multilevel mild lumbar spine discogenic disease, most pronounced at L3-L4, interval decrease in left foraminal disc protrusion at L4-5 measuring 3 mm and contributing to moderate left lateral recess narrowing, and probable contact traversing the left L5 nerve root. Imaging also shows impression of multilevel mild foraminal stenosis and no significant lumbar spinal canal stenosis. The medical records document prior positive responses to transforaminal epidural steroid injections (TFESIs), which have significantly improved the patient’s lumbar radicular pain.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for total disc arthroplasty. Lumbar total disc replacement (arthroplasty) is a good surgical option for relatively young patients with discogenic low back pain, with or without radiculopathy, which is limited to one or two spinal levels, as approved by the U.S. Food and Drug Administration (FDA). Lumbar total disc replacement is more suitable for patients with discogenic lumbar pain without significant spinal canal stenosis, facet joint arthritis or spinal instability. Multiple studies have demonstrated the non-inferiority of lumbar disc replacements compared to fusion in terms of clinical outcomes and back pain relief, while maintaining normal vertebral disc mobility compared to lost motion associated with fusion.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure for the back at L5-S1. A study found that patients treated with basivertebral nerve (BVN) ablation showed significant improvement in pain and visual analog scale (VAS), which was sustained out to five years. One study reported improved Oswestry Disability Index (ODI) and pain scores with BVN at the three month endpoint. Another study similarly reported improved VAS and ODI in patients who underwent BVN ablation. In addition, the American Society of Pain and Neuroscience (ASPN) guidelines note that BVN ablation has received a Level A grade for high certainty that the net benefit is substantial in appropriately selected patients.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for percutaneous image-guided lumbar decompression at the L4-5. Per the medical records, patient has low back pain characterized by throbbing, dull/aching, cramping, and shooting with a sensation of pins and needles. A physical examination of the lumbar spine revealed a restricted range of motion in flexion and extension, limited lateral bending due to pain, bilateral paravertebral muscle tenderness, and positive lumbar facet loading. The patient has tried conservative treatments. Magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel degenerative change of the lumbar spine, with mild-to-moderate spinal stenosis at L3–4 and up to moderate foraminal stenosis.

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 inflam pain oth dorsalgia, then check the rights and deadlines that apply to your plan.