Lumbar Spinal Stenosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) for treatment of the enrollee’s lumbar degenerative disc disease at L3-4 and L4-5. Findings: Two physician reviewers found that the request for left synovial cyst excision at L3-4, L3-5 partial laminectomy/foraminotomies (Coflex implant) is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. Kumar and colleagues performed a literature review to assess whether additional implantation of Coflex following spinal decompression provided better clinical outcomes compared to decompression alone for symptomatic lumbar spinal stenosis (LSS) and to determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000). Wood and colleagues recommended that fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. Researchers support surgery for spinal stenosis in patients who do not improve with conservative treatment. The authors noted that the inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Studies concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain refractory to nonsurgical care in the setting of disc degeneration.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided. Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for authorization and coverage for the Vertiflex device including related surgical services.The Superion® Interspinous Spacer, also known as Vertiflex®, is a titanium implant that is delivered percutaneously to relieve back pain caused by lumbar spinal stenosis (Kaye, et al.) When a patient has established lumbar stenosis and has failed conservative treatment, the standard treatments are decompressive laminectomy, laminectomy with pedicle fixation at one or more levels, or laminotomy combined with interlaminar stabilization. According to the U.S.

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 spinal stenosis, then check the rights and deadlines that apply to your plan.