Lower Back Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s abdominal pannus and are not reconstructive in nature. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patient’s medical condition and are reconstructive in nature. Therefore, the Health Plan’s denial should be overturned. The patient has a significant lower abdominal pannus secondary to weight loss. The patient is noted to have functional impairment related to chronic intertrigo and chronic lower back pain associated with their overlapping lower abdominal skin and pannus. The patient's back pain has been treated conservatively with analgesics.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for any or all of the chiropractic services provided by Dr. Douglas DeSalvo on 9/21/20, 9/30/20, 10/01/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/16/20, 10/19/20, 10/23/20, 10/26/20, 10/30/20, and 11/02/20.Evans and colleagues found, “Spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months.” Additionally, Goertz and colleagues concluded, “Chiropractic manipulative therapy (CMT) in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care.” In this case, the patient presented with right shoulder and lower back pain. The patient has chronic pain and has received chiropractic care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure (destruction of intraosseous basivertebral nerve including fluoroscopy). The U.S. Food and Drug Administration (FDA) notes that the Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with type 1 or type 2 Modic changes on an MRI such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (type 1 Modic change), and changes to the verteb…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to an orthopedic specialist. In an article summarizing the evaluation and treatment of musculoskeletal causes of chest pain, researchers explain, “Conditions such as costochondritis, rib pain caused by stress fractures, slipping rib syndrome, chest wall muscle injuries, fibromyalgia, and herpes zoster are discussed, with emphasis on evaluation and treatment of these and other disorders. Many of these conditions can be diagnosed by the primary care clinician in the office by history and physical examination.

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