Lumbar Degenerative Disc Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) for treatment of the enrollee’s lumbar degenerative disc disease at L3-4 and L4-5. Findings: Two physician reviewers found that the request for left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Kumar and colleagues performed a literature review to assess whether additional implantation of Coflex following spinal decompression provided better clinical outcomes compared to decompression alone for symptomatic lumbar spinal stenosis (LSS) and to determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Activ-L4-5 disc replacement surgery: lumbar arthroplasty procedure. While lumbar spinal fusion has long been considered the gold standard for the treatment of lower back pain related to isolated degenerative disease, a wealth of current medical literature supports the use of lumbar disc arthroplasty for the treatment of this condition. Researchers note that while lumbar fusion may result in adjacent segment degeneration and acquired spinal instability, total disc replacement significantly improves the state of lumbar function and alleviates the pain of degenerative disc diseases, improving the patients’ quality of life.

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested reimbursement for (1) total disc arthroplasty and (2) one-day hospital stay. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for the treatment of up to two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.

The patient is a 50-year-old female who was involved in a bus accident in 1999. She underwent a C6-7 anterior cervical discectomy and fusion in February 2004. Post-operatively she apparently developed significant low back pain with radiation into the left posterior thigh and numbness and tingling in the plantar foot and pain radiating to the bilateral anterior thighs. An MRI of the lumbar spine performed in March 2004 showed minimal disc disease at L4-5 causing mild left neural foramen stenosis, which was unchanged. The patient was seen for a neurology consult in March 2004 for chronic upper and low back pain with mild facial pain. Reflexes were physiologic and her gait was normal.

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 lumbar degenerative disc disease, then check the rights and deadlines that apply to your plan.