Post Laminectomy Syndrome: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin 30 mg and OxyContin 40 mg for the treatment of the enrollee’s chronic pain. Findings: The physician reviewer found that the patient is on high dose opiates for post-laminectomy syndrome. The Health Plan has denied coverage for OxyContin 30 mg and OxyContin 40 mg. However, the patient was left without a viable plan for pain control. The Centers for Disease Control and Prevention (CDC) guidelines describe the appropriate approach for treating patients in this clinical setting.

A 43-year-old female enrollee has requested coverage for 12 additional physical therapy (PT) visits for treatment of her lumbago and post-laminectomy syndrome. Findings: The physician reviewer found that this patient’s back condition has persisted despite surgery at the L4-5 lumbar spine such that she was diagnosed with post-laminectomy syndrome. The patient continues to experience back pain despite 12 sessions of PT. Based on the time course of the patient’s back pain (greater than 6 months of continuous pain), it is deemed that patient has chronic low back pain. Managing chronic low back pain requires a multidisciplinary approach involving medical management and PT. This patient has already been referred to a pain specialist by her primary care physician and undergone a course of PT.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollee’s recurrent back pain. Findings: Two physician reviewers found that the patient was status post L4/5 microdiscectomy. The treating provider’s report indicated that the patient received one week of pain relief following the caudal and left L5 transforaminal epidural steroid injections. She reported that she also had pain on the right and left lumbar areas with burning and shooting pain down her legs. She felt like her back and legs were going to give out. A lumbar spine examination documented normal alignment and no tenderness to palpation. Range of motion was documented as flexion 90 degrees, extension 15 degrees, and negative straight leg raise at 70 degrees. Lower extremity neurologic examination was reported within normal limits.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Percocet 10 mg (one tablet every four hours) and/or morphine ER 30 mg (one tablet every four hours), and if not, Percocet 10 mg (one tablet every six hours) and/or morphine ER 30 mg (one tablet every six hours).Findings: The physician reviewer found that a review and meta-analysis evaluating opioid use for the treatment of patients with chronic non-cancer pain concluded that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. However, the authors did not find that opioids were superior to non-opioid therapy for non-cancer pain.

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 post laminectomy syndrome was denied, the published record says the denial is worth fighting.