Radiculopathy: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multi-level lumbar spinal fusion surgery (CPT code 22614) at L4-L5 and L5-S1.Researchers have concluded that lumbar fusion may be considered an option for patients with degenerative disc disease and disc herniations with radiculopathy when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. Authors have concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic lower back pain that is refractory to nonsurgical care when a diagnosis of disc degeneration can be made. Studies recommend surgery for spinal stenosis for patients who do not improve with conservative treatment.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Researchers noted that low back pain continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. One study concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. This patient presented on several dates for follow-up of low back pain with left leg radiation. Initially, the patient reported painful radiculopathy with reduced function and activities of daily living. The patient’s range of motion was decreased due to pain and straight leg raise was positive.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) L5-S1 anterior lumbar interbody fusion surgery and (2) L4-L5 fusion surgery. Medical literature state, “A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.” Researchers state, “Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy.

Physician 1: The patient is a 26-year-old male with a history of low back pain and radicular symptoms to both legs, dating back to 2001. Conservative treatment had not been effective. MRI showed disc protrusions at L4-5 and L5-S1, but no frank nerve root compression and no clinical neurological deficits were described. Two-level endoscopic discectomy/thermal annuloplasty at L4-5 and L5-S1 was recommended by the patient’s provider and carried out In March 2006. The patient requested reimbursement from the Health Plan for the costs incurred. The Health Plan denied the patient’s request stating that percutaneous techniques for lumbar, thoracic or cervical discs, with or without endoscopic guidance, are considered investigational and were therefore not a covered benefit.

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