Neck Problem 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: An enrollee has requested reimbursement and prospective authorization and coverage for greater and lesser occipital nerve block injectios. Current medical literature supports the safety and efficacy of occipital nerve blocks as the initial treatment of choice for occipital neuralgia. The International Headache Society (IHS) defines occipital neuralgia as paroxysmal stabbing pain, with or without persistent aching between paroxysms, in the distribution(s) of the greater, lesser and/or third occipital nerves. The IHS notes that tenderness to palpation over the affected nerve with temporary pain relief after an anesthetic block is also required to meet the definition. Pain may be unilateral or bilateral with radiation into the temple or even behind the eye commonly triggered by head movements.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral peri-implant capsulectomy and bilateral breast implant removal. Capsular contracture is a complication of breast implants that may require revision surgery. The authors noted that “Capsular contracture initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. When an implant is placed, a fibrous capsule forms around it. In a normal breast, the capsule is thin and soft, with no effect on the appearance of the breast. In a contracted breast, the capsule becomes thick and hard, and shrinks in a way which alters the contour of the breast and the position of the implant.” A study describes the Baker classification of capsular contracture after breast augmentation. Grade I capsular contracture is asymptomatic.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction and/or trunk lipectomy. With regard to the requested breast reduction, researchers stated that reduction mammaplasty should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two signs such as chronic breast pain due to the weight of the breasts, shoulder grooving, intertrigo unresponsive to medical management, headache, or congenital breast deformity. The records document that this patient complains of back, shoulder, and neck pain. However, there is a lack of documentation of shoulder grooving by physical examination or by photographs.

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