Muscle Spasms denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 38-year old woman who sustained a cervical injury in 1994 as the result of a physical assault. She has had a cervical fusion, left thoracic outlet decompression, and right scalenectomy since the incident. She has chronic pain due to muscle spasms in the neck, shoulders and back. More conservative treatments did not completely resolve her symptoms and she began Botox injections in 2003 and indicates that her symptoms have improved significantly. The patient is requesting coverage for continued treatment with Botox injections. The Health Plan considers the treatment investigational and has denied coverage.A review of the literature fails to confirm the safety and efficacy of Botox injections for pain due to thoracic outlet syndrome or cervical radiculopathy. With regard to this patient, it is not clear that Botox injections are the best treatment alternative.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Fentanyl transdermal system, 100 mcg, 15 patches per month (Please note: ten patches per month have been approved by the Health Plan.). On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral breast reduction surgery. The American Society of Plastic Surgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on documentation of the severity of the symptoms of macromastia and its impact on health-related quality of life. The ASPS guidelines indicate that reduction mammaplasty may be indicated if at least two of the following quality-of-life signs are present: chronic breast pain due to breast weight, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache, and…

Physician 1: The patient is a 51-year-old woman with episodic dizzy spells, leg weakness, and fear of losing consciousness after cervical spine surgery. She finds Botox is helpful for these symptoms. The history provided by the patient does not make mention of migraine headaches, though the physician’s report suggests the primary indication in this patient is a diagnosis of migraine. It is not clear from the information provided whether there has been subsequent worsening upon withdrawal of Botox. The Health Plan has denied coverage for Botox therapy on the basis it is considered investigational. There is no evidence that Botox is useful for spells of dizziness, leg weakness, and fear of losing consciousness. Additionally, the records provided do not support a diagnosis of migraines.

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 muscle spasms, then check the rights and deadlines that apply to your plan.