Lumbar Facet Arthropathy denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving lumbar facet arthropathyand overturned the plan’s denial in 46.2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 10 | 40% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation.American Society of Interventional Pain Physicians evidence-based guidelines for interventional techniques state that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. A systemic review by Manchikanti and colleagues found that in the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy. Researchers found that there was a reduction in pain 12 months post-procedure for patients with facet joint disease of the lumbar spine. Researchers found that radiofrequency ablation of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6-12 months and possibly up to 2 years.
A 45-year-old male enrollee has requested left side neurotomy for treatment of his lumbar facet arthropathy and radiculopathy. Findings: The physician reviewer found that based on review of the available records, the facet block on the left L3-4, 4-5 and L5-S1 joints under fluoroscopy as well as the fluoroscopically guided rhizotomy of the left L3, 4, 5 and S1 medial and lateral branches done on the said date was medically necessary as part of an appropriate work-up consistent with the standard of care. In addition, the epidural injection CPT 62311 (with fluoroscopy 77003) on the date in question was done for what appeared to be reasonable suspicion of radicular impingement.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for platelet rich plasma injections. The guidelines on the use of biologics, including platelet rich plasma, for lumbar facet arthropathy note that at present, there is very little literature regarding the application of stem cells in the treatment of facet joint and sacroiliac joint pain. The further notes that a methodologic quality assessment of lumbar facet intraarticular injections reported that due to the limitations of three studies, a meta-analysis could not be performed.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for platelet rich plasma (PRP) injections. The American Society of Interventional Pain Physicians (ASIPP) guidelines on the use of biologics, including PRP, for lumbar facet arthropathy note that at present, there is very little literature regarding the application of stem cells in the treatment of facet joint and sacroiliac joint pain. The ASIPP further notes that a methodologic quality assessment of lumbar facet intraarticular injections reported that due to the limitations of three studies, a meta-analysis could not be performed.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 facet arthropathy, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY