Sciatica denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for Belbuca films. In a meta-analysis and review of 33 studies looking at the use of buprenorphine in chronic pain, researchers concluded, “Buprenorphine is an atypical opioid that demonstrates efficacy similar to that of Schedule II full μ-opioid receptor agonists in managing chronic pain while exhibiting a favorable tolerability profile, including the reduced likelihood of abuse potential and respiratory depression.” Researchers report that consensus guidelines on the use of buprenorphine for chronic pain management recommend that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile based on metabolic factors, abuse potential, and tolerability, and that buprenorphine be continued during the perioperative/trauma period…

The enrollee is requesting authorization and coverage for transforaminal epidural steroid injections, Norco 10/325, and Flexeril, 10mg. The enrollee has low back and right leg pain. The enrollee received a right lumbar transforaminal block. She has chronic, disabling pain, which has caused psychological, social, and physical impairment. Conservative treatments have been used without relief. These include non-steroidal anti-inflammatory drugs and physical therapy. The record indicated her blood level of Norco was within normal limits and her urine toxicology screen was also normal, with no use of illicit substances. The enrollee indicates with her current pain medications, she was able to feel better, sleep more and be more active. She did not report any side effects related to the pain medication.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for no tapering of Norco and/or magnetic resonance imaging (MRI) of the bilateral hips and knees. Per the American College of Radiology (ACR) recommendations, the requested MRI of the bilateral hips and knees is not medically necessary for evaluation of this patient. The ACR noted that, “Depending on history and physical examination, imaging may not be necessary to evaluate all hip pain” (Mintz, et al.). The ACR states that for chronic hip pain and low back, pelvic, or knee pathology where the goal is to exclude hip as the source, “radiographs negative, equivocal, or showing mild osteoarthritis.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) cervical and lumbar spine. In this case, x-rays of the left wrist/forearm/humerus/elbow were unremarkable. A cervical x-ray showed fusion at C6-C7 and moderate C5-C6 degenerative disc disease. Notes report diagnoses including chronic neck pain, numbness of the fingers, and acute midline low back pain with left-sided sciatica. The patient reported tingling in the left arm along with numbness of the fingers. She reported three weeks of left-sided sciatica.

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