Lumbar Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a series of three intra-articular injections of hyaluronic acid, a third epidural steroid injection, and celecoxib. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited.

A 61-year-old male enrollee has requested right L3-4 microdecompressive lumbar laminectomy, removal of the lesion (tumor versus cyst) for decompression, provocative lumbar discogram and epidural for the treatment of his lumbar pain. Findings: The physician reviewer found that of the services at issue, removal of the lesion for decompression and the right L3-4 microdecompressive lumbar laminectomy were medically necessary, but the provocative lumbar discogram and the epidural were not medically necessary. The excision of the synovial cyst through a technique of open micro-laminectomy with operating microscope was appropriate and indicated. The cystic lesion needed to be addressed surgically. The pathology report ruled out tumor.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar fusion of the L4-5 and L5-S1. Findings: The physician reviewer found that prospective methodology with a broad definition of complications, Campbell and colleagues reported a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, the authors noted a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

Findings: The physician reviewer found that the patient requested authorization and coverage for a platelet-rich plasma injection.Platelet-rich plasma (PRP) injections have demonstrated some efficacy in the treatment of lumbar and sacroiliac joint pain. At present, however, there is evidence indicating the need for larger and more carefully controlled prospective studies. The authors of a study indicated that there is evidence that PRP injections may be a more effective option compared to corticosteroid injections. However, the authors concluded that randomized controlled trials with longer-term follow-up are still necessary to compare its long-term efficacy. The early results from the studies look promising but PRP injections cannot be considered over the standard of care until further studies have been conducted.

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