Neck Pain 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 magnetic resonance imaging (MRI) of the cervical spine (CPT 72141) and/or MRI of the lumbar spine (CPT 72148). With regard to the requested lumbar spine MRI, Srinivas and colleagues reported on a systematic review of the literature and “found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging versus usual care.” Furthermore, the authors noted that, “high-quality consistent evidence shows that imaging patients with acute low back pain of less than six weeks’ duration and no red flag symptoms results in no clinical benefit but is associated with harms.” Wang and colleagues stated that, “most acute episodes of low back pain are self-limiting, and imaging has limited utility because most patients with low back pain have nonspecifi…

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) oxycodone-acetaminophen 10-325 mg (30 tablets for a 15-day supply), and (2) oxycodone-acetaminophen 10-325 mg to be filled for a 30-day supply. The Washington Agency Medical Directors’ Group guidance on prescribing opioids postoperatively recommends prescribing the lowest effective dose strength in cases of severe pain for 14 days or less. The authors note that for exceptional cases warranting more than 14 days of opioid treatment, the surgeon should reevaluate the patient before refilling the prescription and taper the patient off opioids within six weeks after surgery. On determining when to initiate or continue opioids for chronic pain, researchers report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for referrals to head and neck surgery, maxillofacial surgery, chiropractic, cardiology, pulmonology and a bone density test for evaluation of the enrollee’s neck pain, back pain, chest pain, and headaches. Findings: The physician reviewer found that with regard to the request for referral to head and neck surgery and referral to maxillofacial surgery, the records indicate that the patient was previously evaluated by a head and neck surgeon. This evaluation included a history, an examination, an assessment and plan. The provider did not find that the patient was a candidate for any surgical intervention and recommended treatment with corticosteroid nasal spray and salt water nasal spray. Further, the patient had subsequent imaging of the sinuses and nasal septum both with CT and MRI.

Physician 1The patient is a 38-year-old female with a number of medical issues including long- standing muscle tension headaches, degenerative cervical and lumbosacral spine disease, and psychiatric problems. Some of these problems appear to stem from an injury that the patient sustained as the result of a fall in August 2002. The patient has consulted several physicians and has attempted treatment with several different medications. She has received Botox injections that she reports have resulted in relief of her symptoms. She now wishes to continue with Botox injections. The Health Plan has denied authorization and coverage for Botox therapy on the basis that it is considered investigational. To date, the long-term efficacy of Botox injections for treatment of the patient’s medical problems has not been established.

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 neck pain, then check the rights and deadlines that apply to your plan.