Neck Problem: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested acupuncture for treatment of her neck, shoulder and back pain. The physician review found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. According to the documentation submitted for review, the patient previously underwent acupuncture sessions which were documented as beneficial. Gains were described as symptom reduction, medication intake reduction and range of motion improvement. According to the patient, the benefits obtained from acupuncture were superior to benefits obtained with physical therapy, nerve blocks and epidurals.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene mutation test prothrombin G20210A (Factor II). Findings: Three physician reviewers found that this testing is likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. DVT and pulmonary embolism may be caused by hereditary thrombophilias. The increased risk is worth knowing, especially in situations of estrogen therapy, prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions. There are also known interactions between drugs and other variables and gene mutations in Factor V or II. For example, there is a known interaction between estrogens and the Factor V mutation. There is extensive literature supporting the testing that was done in this case.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography angiography (CTA), facet joint injections and nerve blocks for treatment of the enrollee, who has a history of degenerative disc disease and neck pain. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The American College of Radiology states that CTA may be indicated if spinal arteriovenous malformations or dural arteriovenous fistulae are considered to be likely causes of slow progressive myelopathy and may also be useful in evaluating the intra-cranial and extra-cranial blood vessels for patients with sudden development of a single focal neurological deficit suggesting a vascular ischemic event such as an infarction.

Nature of Statutory Criteria/Case Summary: An enrollee has requested low back and cervical spine surgery for treatment of his medical condition. Findings: The physician reviewer found that there is a lack of support for the requested services in this patient’s case. Relative to the cervical spine, this patient reports continued severe neck pain radiating to the middle of his back with bilateral arm numbness and weakness. He reported a history of non-specific surgery for these symptoms, without improvement. The most recent imaging of the cervical spine documented cervical cord compression and nerve root compromise. There is no documentation of current clinical findings or conservative treatment relative to the cervical spine. A recent electromyography/nerve conduction study did not evidence cervical radiculopathy, but did document findings consistent with carpal tunnel syndrome.

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