Low Back Pain With Radiculopathy: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the middle spine and/or right knee. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain, for an adult patient with initial radiographs demonstrating degenerative changes, an MRI may be appropriate as the next imaging examination, if the patient's symptoms are not explained by the radiographic findings. In this case, the patient’s pain persists despite conservative management and were not explained by radiographic findings. Therefore, an MRI is appropriate, and he may be a surgical candidate.

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar for evaluation of her back pain. The physician reviewer found that the American College of Radiology (ACR) has established criteria for the evaluation of low back pain and defined several variants such as acute low back pain, post-traumatic low back pain, low back pain in cancer patients, low back pain with radiculopathy, low back pain in patients who have had prior lumbar surgery. The ACR reports that MRI is not warranted in the acute setting. However, the ACR criteria support the utility of MRI in the setting of low back pain with radiculopathy in which the patient is a candidate for surgery or other intervention.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy and epidural steroid injection. Findings: The physician reviewer found that there is a lack of supporting documentation such as chest x-rays, chest computed topography, sinus computed topography, pharmacy antibiotic records or antibiotic log to confirm this diagnosis. A single set of laboratory results show a low total IgG, but there is no repeat of laboratory work up to confirm. Moreover, there is a lack of evaluations for other signs of protein loss, and there is no specific antibody titers of pre- and post- vaccination titers. The records provided do not clearly evaluate the patient’s ability to respond to infections or lack thereof as required for the diagnosis of common variable immunodeficiency (CVID).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) procedure code 72148. Findings: The physician reviewer found that the utility of MRI for patients with low back pain and radiculopathy and surgical intervention candidates with persistent or progressive symptoms during or following six weeks of conservative management. The ACR guidelines support MRI only if severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate for invasive treatment approaches. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. This patient is being treated for bilateral low back pain with radiculopathy.

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 low back pain with radiculopathy was denied, the published record says the denial is worth fighting.