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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested an office/outpatient visit (CPT code 99215) and office consultation with an orthopedic medical group (CPT code 99245) for treatment of his herniated disc. The physician reviewer found that evidence based medical peer-reviewed literature supports surgical evaluation and treatment of lumbar disc herniation as well as pain management for treatment of epidural scarring. This patient presents status post L4-5 laminectomy and repeat laminectomy with persistent low back and radicular pain with significant myelopathy. There is current imaging evidence of a new disc herniation at the L5-S1 level with annular tear extending into the neural foramen and associated moderate neuroforaminal narrowing.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage 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 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 lumbar radicular back pain due to severe lumbar disc degeneration and spinal stenosis.

Where the denial was upheld

Physician 1: The patient is a 21-year-old male with a lumbar disc herniation at the L2-3 level. His condition is described as stable with lower back, buttock, and right leg pain. He reports his pain as moderate and tolerable. He has not been able to return to his usual activity level and corrective surgery consisting of decompressive laminotomy and discectomy was recommended. Lumbar traction was discussed and the patient requested a referral. He consulted with a chiropractic office and VAX-D treatments ensued. Approximately 30 sessions were provided with apparent positive results.

A 43-year-old female enrollee has requested authorization and coverage for lumbar spinal fusion surgery to remove and replace hardware on an inpatient basis for treatment of the enrollee’s low back and right buttock, leg and groin pain. Findings: The physician reviewer found that in a comprehensive review of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick and colleagues examined 389 titles and abstracts. “References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.” Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies.

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 herniation was denied, the published record says the denial is worth fighting.