Low Back Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine (CPT 72141) and/or MRI of the lumbar spine (CPT 72148). With regard to the requested lumbar spine MRI, Srinivas and colleagues reported on a systematic review of the literature and “found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging versus usual care.” Furthermore, the authors noted that, “high-quality consistent evidence shows that imaging patients with acute low back pain of less than six weeks’ duration and no red flag symptoms results in no clinical benefit but is associated with harms.” Wang and colleagues stated that, “most acute episodes of low back pain are self-limiting, and imaging has limited utility because most patients with low back pain have nonspecifi…

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facet injections and Percocet 10mg (60 per 30 days). The current medical evidence does not support facet injections in this clinical setting. A randomized control trial regarding the use of facet joint blocks concluded that facet blocks are not therapeutic (Cohen, S., et al.). The trial also concluded that higher responder rates in certain treatment groups suggested that facet blocks might provide prognostic value before radiofrequency ablation. American Society of Interventional Pain Physicians (ASIPP) guidelines for interventional techniques in chronic spinal pain stated that the evidence for therapeutic lumbar facet joint blocks is weak.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) aqua therapy three times per week for eight weeks, (2) one-on-one physical therapy two times per week for eight weeks, (3) Norco (5 mg/325 mg tablets for 60 days), and (4) dexamethasone (4 mg tablets for 60 days).Findings: The physician reviewer found that Heywood and colleagues report that it is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions.

Physician 1: The patient is a 39-year-old female with a history of work-related low back pain. She is status post two spinal surgeries and has undergone multiple treatment modalities including massage therapy, acupuncture, and myofascial trigger point injections without sustained relief. The patient is maintained on high-dose narcotics for pain control and continues with severe pain, which has a spastic component and is made worse with straight leg raising. Her most recent MRI of the lumbosacral spine in January 2000 demonstrated mild to modest spinal stenosis at L4-5 secondary to a very broad based central and right paramidline disc protrusion and degenerative disc changes at L5-S1. The consulting pain management specialist has recommended an epiduroscopy for evaluation/treatment of the patient’s continued back pain.

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