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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Intracept spine procedure. The U.S. Food and Drug Administration (FDA) has approved the Intracept procedure for use in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae. The FDA has endorsed use of the Intracept procedure for patients with chronic low back pain of at least six months duration that has not responded to at least six months of conservative care accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI. This patient has history of spondylosis without myelopathy or radiculopathy, lumbar region, disease of the musculoskeletal system and connective tissue, and other intervertebral disc degeneration, lumbar region.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucynta 50 mg Extended Release tablets. Findings: The physician reviewer found that guidelines state that when opioid therapy is used, a patient’s regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, “Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.” In this case, the patient has chronic low back pain due to lumbar spondylosis. The provider charted that the patient has been able to successfully manage her pain with a combination of long- and short-acting Nucynta. The patient reported increased back and neck pain and she requested an adjustment to a long-acting medication.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Intracept procedure (destruction of intraosseous basivertebral nerve including fluoroscopy). The U.S. Food and Drug Administration (FDA) notes that the Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with type 1 or type 2 Modic changes on an MRI such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (type 1 Modic change), and changes to the verteb…

The patient has requested authorization and coverage for facet joint injection of the lumbar and lumbosacral spine, and hydrocodone-acetaminophen (Norco). Findings: A medical study reported the safety and efficacy of therapeutic medial branch blocks in the treatment of low back pain. The study concluded that the findings establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. These findings are consistent with an earlier study, which concluded that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement.

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