Lumbar Disc Degeneration: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a lumbar epidural steroid injection. The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend epidural steroid injections for patients with chronic low back and/or lower extremity pain of at least three months which has failed to respond to noninterventional and nonsurgical conservative management resulting from disc herniation or lumbar radiculitis. According to one medical study, “There is evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation.” In this case, the patient has a history of chronic back pain due to severe lumbar disc degeneration and multiple level stenosis. The patient has undergone trials of conservative care with chiropractic care, home stretching, and medication management without benefit.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injection(s). The American Society of Interventional Pain Physicians (ASIPP) recently published guidelines regarding evidence supporting epidural steroid injections in the treatment of patients with chronic spinal pain (Manchikanti, et al.). The ASIPP guidelines noted that for patients with spinal stenosis “The evidence based on one high-quality randomized controlled trials in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation.” In addition, “The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis for treatment of the enrollee’s lumbosacral spondylosis.Findings: Three physician reviewers found that the enrollee has a history of knee pain, lumbar radiculopathy, osteoarthritis of the hip, and lumbar disc degeneration. The patient presented to her provider on 2/5/16 and reported pain in the back and upper left leg. The patient described this pain as constant, shooting, worse with activity and better with medications. The pain had begun two months prior to the visit in February. The patient had tried heat, ice, and transcutaneous electrical nerve stimulation. Per the patient, the treatments helped some. Straight leg raise was positive on the left. The patient had pain with extension and flexion of the lumbar spine.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous injection of allogeneic cellular and tissue-based product, intervertebral disc. This patient is treated for dorsalgia and disc degeneration of the lumbar spine. The provider noted that the patient presents with ongoing low back pain and numbness that goes down the bilateral lower extremities. The patient reports that her symptoms interfere with her ambulation. The patient’s previous examination was noted to show pain to palpation over the cervical paraspinous muscles, full range of motion in lumbar spine, and pain on palpation over the lumbar paraspinals. The pat demonstrated positive facet loading, sacroiliac joint tenderness, with positive Patrick’s, Gaenslen’s, and sacroiliac joint compression tests.

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 lumbar disc degeneration was denied, the published record says the denial is worth fighting.