Home / Conditions / Facet Arthropathy
Facet Arthropathy: when insurers say no, reviewers often say yes
In 22 published external-review decisions involving facet arthropathy, independent physician reviewers overturned the insurer’s denial 50% of the time.
Published decisions
22
2001–2026
Overturned
50%
11 denials reversed
Most-fought treatments for facet arthropathy
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Radiofrequency Ablation | 3 | 66.7% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 13 | 53.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 44.4% |
Typical time to a decision
7 days
Most land between 3 and 20 days
Handled as urgent
54.5%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for bilateral L4-L5 and L5-S1 lumbar steroid facet injection with intraoperative fluoroscopic guidance with interpretation performed under monitored anesthesia care (MAC) and authorization and coverage for bilateral radiofrequency ablation of the L3-L4 and L4-L5 paravertebral facet joint nerves with fluoroscopy or computer tomography (CT) imaging guidance. In this case, the patient presented with chronic lumbar spine pain that was not responsive to conservative measures, including physical therapy and medication. The records indicate that the patient had multiple low back pain generators, including sacroiliac joint dysfunction, facet arthropathy, and coccydynia. The patient initially underwent a bilateral L4-L5 and L5-S1 facet joint injection and experienced a 60% improvement in symptoms.
A 52-year-old female enrollee has requested authorization and coverage for a lumbar facet rhizotomy for treatment of the enrollee’s chronic low back pain. Findings: Two physician reviewers found that the patient presents with chronic axial low back pain that is believed to be caused by facet arthropathy at L4-5 and L5-S1, as well as a possible sacroiliac joint trigger. The patient is status post anterior fusion at the L4-5 and L5-S1 levels with good anterior fusion mass, but no/limited fusion of the facet joints or posterior elements. The patient has consulted a surgeon, who has stated there is no current indication for further surgery at this time and the other lumbar levels appear to be free of neurocompressive lesions. The patient’s history demonstrates a good response to facet rhizotomy a couple years ago and more recently, temporary but good relief to diagnostic facet injections.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1: The patient is a 50-year-old female with facet arthropathy, spinal stenosis, degenerative disc disease and spinal radiculopathy. She has had significant pain and underwent facet joint injections and lysis of adhesions to treat her condition. The patient reported that the procedures were helpful in relieving her symptoms. She has requested reimbursement and continued authorization and coverage for the facet joint injections and lysis of adhesions. The Health Plan denied her request based upon a determination that the procedures are experimental/investigational in this clinical setting.There is no class I data to support the use of facet joint injection or lysis of adhesions in cases of degenerative lumbar spinal stenosis or disc degeneration.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar (CPT-22857), with posterior redo decompression left L4-5 and possible L5-S1. Findings: The physician reviewer found that In this case, there are several concerns regarding the patient's condition. The patient has seen several physicians and there is not a consensus about her condition and the need for surgery. There is not a consensus about what the patient’s MRI testing shows, what her complaints are, or what her physical examinations have noted. The patient has a complex pain syndrome that is not made simpler by her complex regional pain syndrome and fibromyalgia.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for facet arthropathy was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.