Discogenic Low Back Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 42-year-old female with chronic discogenic low back pain secondary to internal disc derangement at L4-5 and L5-6. The patient underwent provocation discography on 8/17/04 demonstrating diffuse annular disruption at L4-5 and midline radial fissure at L5-6. The patient’s provider has recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan indicates the requested procedure is considered experimental and has not been established as more effective than available standard therapies.Review of the submitted clinical information indicates the patient is not a candidate for microdisectomy, fusion or chemonucleoplasty. In addition, the patient has not had significant relief from other treatments utilized such as medications, epidural injections, and facet joint block injections.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for steroid injection of the lower back. The American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural interventions for chronic spinal pain reviewed the evidence related to the use of epidural steroid injections for discogenic back pain. The ASIPP noted that, “The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality randomized controlled trials in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids”.

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 percutaneous injection of allogeneic cellular and/or tissue-based product administered to the lower back. A multicenter, prospective, randomized controlled trial assessed the use of VIA Disc compared to saline injections in patients with chronic discogenic low back pain. While the study reported improved pain and function scores at one year in the treatment arm, limitations of the study included a relatively small sample size, lack of long-term follow-up beyond 12 months, and strict inclusion criteria that may not apply to general patient populations. Another study showed that nucleus pulposus (NP) allograft supplementation in patients with lumbar discogenic pain resulted in improvement in pain and function over six months.

Physician 1The patient is a 35-year-old female who has a history of severe intractable low back pain with radiation to the buttocks and hips bilaterally. She has undergone conservative treatment with no long-term benefit. The patient would like to undergo intradiscal electrothermal therapy (IDET), which is considered investigational by her Health Plan.IDET remains an unproven therapy without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of low back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

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