Lumbar Stenosis denials in California external review
In the California DMHC record, independent physician reviewers decided 22 published external-review cases involving lumbar stenosisand overturned the plan’s denial in 18.2%. 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. | 13 | 30.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zohydro ER 30 mg capsule once every 12 hours. In terms of dosage, the American Society of Interventional Pain Physicians (ASIPP) state that 40 morphine milligram equivalents (MMEs) is low dose, 41 to 90 MME is a moderate dose, and greater than 91 MME is high dose. In this case, the patient has chronic pain from lumbar stenosis and left lumbar radiculopathy per the provider’s notes. She has lumbar scoliosis with degenerative disc disease affecting L4-5 level. The patient is a candidate for spine surgery, but has been unable to move forward with surgery, as she is the primary caregiver in her home. She is currently actively participating in a home exercise program including yoga, which reportedly is helpful in managing her pain.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal epidural injections.A 2018 systemic review by Lee and colleagues concluded that lumbar epidural steroid injections were more effective injections than those without steroid for improved pain relief and function. Manchikanti and colleagues concluded in their 2013 update of guidelines that for lumbar disc herniation with radiculitis, the evidence is considered good for short-term and long-term relief with local anesthetics with steroids. They stated that the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis.In this case, the patient has low back pain with radiation into the lower extremities.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for basivertebral nerve ablation- thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral. Findings: The physician reviewer found that the patient was treated for lower back pain, lumbar stenosis, sacroiliac joint dysfunction, and lumbar disc disease. The patient’s treatment plan included Intracept basivertebral nerve ablation at L3 and L4. The patient’s recent MRI of the lumbar spine demonstrated endplate Modic changes at L3-4 and inferior L3 endplate Schmorl’s node.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone 20 mg five times a day. At issue is whether the requested oxycodone 20 mg five times a day is medically necessary for the treatment of this patient. The updated Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy prescribing state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage.
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 stenosis, 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