Leg Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

A 53-year-old female enrollee has requested a power scooter for treatment her back and left leg pain. Findings: The physician reviewer found that the requested equipment is medically necessary for treatment of the patient’s medical condition. The medical literature supports the requested equipment in this clinical setting. According to Edwards and colleagues, “Power wheelchairs and scooters have the potential to increase community participation for people with mobility limitations.” The authors investigated the characteristics of adults who use power wheelchairs and scooters, the process of power-mobility provision and the benefits and challenges of use.

A 37-year-old female enrollee has requested an magnetic resonance imaging (MRI) of her lower back for an evaluation of her back pain. Findings: The physician reviewer found that some patients have continued or worsening back pain even with conservative therapy. Such is the case with this patient. She has worsening back pain with leg pain in spite of NSAIDs, pain medications, and physical therapy. She has also had cortisone injections but her symptoms continue. At this time, MRI of the lumbar spine is medically appropriate to evaluate for disc herniation or spinal stenosis as a cause of her symptoms. MRI is the exam of choice to evaluate the lumbar spine, and this study will assist in directing the patient’s future treatment properly

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for spinal surgery. This patient experienced short-term relief from right-sided back and leg pain with prior surgery. The operative notes reported that a disc herniation was not found, nor was disc material removed, although there was evidence of local narrowing. Thus, the patient does not have recurrent herniated nucleus pulposus. Since the patient underwent a surgery, he has received eight physical therapy sessions, but there is no indication whether the patient participated in a home exercise program. There is no documentation of failure of at least 12 weeks of conservative management. In addition, the records do not report that he received epidural steroid injections or other injections. He has no documented symptoms or signs nor findings of a lumbar radiculopathy.

A 29-year-old male enrollee has requested coverage for acupuncture services for treatment of his shoulder, arm, leg and entire back pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. According to the documentation submitted for review, the patient has had an unknown number acupuncture sessions for the treatment of his condition. The medical records fail to document a pre-care baseline in order to assess the benefits of an acupuncture trial. In addition, there are no measurable, objective symptoms, functional deficits improvements documented in order to support the medical necessity of the acupuncture services.

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 leg pain was denied, the published record says the denial is worth fighting.