Lumbar Radiculopathy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for artificial disc replacement surgery by anterior approach (CPT code 22857). The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one or 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.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. The records indicate that this patient was being treated for low back pain, herniated nucleus pulposus of the lumbar, lumbar radiculopathy, lumbar disc disorder with myelopathy, and lumbar herniated disc. She presented with a seven-month history of conservatively managed low back pain which has exacerbated over the past two months. The pain radiated into the buttocks and to the left lower extremity with right foot numbness. The patient was admitted for pre-operative clearance and workup to have surgery. She underwent a laminectomy with lumbar microdecompression at right L5-S1 and left L4-5 without complications. The patient was noted to have had a pain crisis. She was emotionally unable to cope.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for no tapering of Norco and/or magnetic resonance imaging (MRI) of the bilateral hips and knees. Per the American College of Radiology (ACR) recommendations, the requested MRI of the bilateral hips and knees is not medically necessary for evaluation of this patient. The ACR noted that, “Depending on history and physical examination, imaging may not be necessary to evaluate all hip pain” (Mintz, et al.). The ACR states that for chronic hip pain and low back, pelvic, or knee pathology where the goal is to exclude hip as the source, “radiographs negative, equivocal, or showing mild osteoarthritis.

The patient has a history of lumbar radiculopathy. In a progress report, the patient reported pain over the upper back (right side greater than left), low back (equally affected on both sides) and the tail bone. The pain was described as sharp, with spasms and throbbing. The pain developed suddenly, and the symptoms had worsened over time. The pain had been present for greater than one year. The pain was rated as eight out of 10 and was moderately affecting the patient’s function. The pain/symptoms were made better with rest and the pain increased with bending forward, arching the back, and repetitive computer work. The physical exam revealed a straight leg raising test was equivocal bilaterally. Five out of five strength was noted in the bilateral lower extremities. Sensation was intact to light touch throughout bilateral lower extremities. 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 radiculopathy, then check the rights and deadlines that apply to your plan.