Scoliosis 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 oxycodone. The Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioid medications assist providers in making decisions regarding initiating, adjusting and discontinuing of opioid therapy. The most recent CDC guidelines state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for services offered by the Scoliosis Academy and Janzen and Janzen Health Center for treatment of the enrollee’s scoliosis. Findings: 2/3 of the physician reviewers found that there is sufficient support in the body of literature as well as the documentation provided for the services at issue in this clinical setting. The patient has shown significant improvements in the curvature following the treatments at the Scoliosis Academy and Janzen and Janzen Health Center. The current medical literature also supports the combined treatments of three dimensional bracing and Schroth physiotherapy exercises. The current conservative treatment plan resulted in objective functional improvements.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for hybrid vertebral body tethering surgery. There is limited published, large-scale, long-term, peer-reviewed literature demonstrating that the requested service is an effective and/or safe treatment for the noted pathology in this case. In this case, the records noted that the patient was diagnosed with scoliosis at age seven, with a 23 degree curve. She started spine core bracing right after the diagnosis. Within the past year, her curve progressed into the 50 degree range despite continued SpineCor® bracing. The patient reported midline lumbar pain and convex right scapular spasms with prolonged standing, with pain that occasionally increases to a six out of ten, although this was uncommon.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 12 additional physical therapy sessions. Kim and colleagues note that scoliosis may present as adolescent idiopathic scoliosis or adult degenerative scoliosis. Berdishevsky note that there are many therapeutic interventions for children with scoliosis, including observation, physiotherapy scoliosis specific exercises (PSSE), and bracing. Lotan and Kalichman note that case reports and small-scale clinical trials of poor methodological quality prevent a clear conclusion about the effectiveness of manual therapy in the treatment of adolescent idiopathic scoliosis.

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