Spinal Cord Injury denials in California external review
In the California DMHC record, independent physician reviewers decided 62 published external-review cases involving spinal cord injuryand overturned the plan’s denial in 45.2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for spinal cord injury
| Category | Decisions | Overturned |
|---|---|---|
| Physical Therapy | 3 | 33.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 35 | 37.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 26 | 57.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a functional electrical stimulation (FES) system (Bioness NESS L300 foot drop system). Van der Woude and colleagues explain that with increasing age and time since injury, patients with spinal cord injury may develop long-term medical complications including spasticity, osteoporosis, fractures, heterotopic ossification, limb edema, muscle atrophy, pressure sores, urinary and respiratory tract infections, contractures, extremity pain, obesity, diabetes, and cardiovascular disease. The authors note that these secondary health conditions associated with an inactive lifestyle may result in reduced societal participation, quality of life, and frequent hospitalizations and that avoiding this downward spiral course and improving physical and mental well-being are crucial in such patients.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for sub-acute rehabilitative services.Nas and colleagues noted, “The treatment and rehabilitation period is long, expensive and exhausting in spinal cord injury (SCI). Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives.” Per Hagen and colleagues, “Knowledge of cardiovascular sequelae after spinal cord injuries and assessment of these is important for correct diagnostics, planning of preventive measures and optimal treatment.” Rosin and colleagues noted, “Skin breakdown, including burns and pressure injuries (PrIs), is a devastating complication of spinal cord injury (SCI).”In this case, the patient has a complicated rehabilitative history related to his spinal cord injury.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for an RT300-SL functional electrical stimulation (FES) therapy system. This patient’s provider has recommended treatment with an RT300-SL FES therapy system to improve overall health status post spinal cord injury. However, the evidence for the effectiveness of the RT300 FES therapy system in patients with spinal cord injuries remains limited. There is insufficient evidence in the literature demonstrating that the use of the RT300 FES will be effective for patients with spinal cord injuries in terms of long-term improvements in muscle strength, vascular blood flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor movement, or reduction muscle atrophy in the upper or lower extremities.
Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for the ReWalk Personal 6.0 Lower Extremity Robotic Exoskeleton System. The enrollee has a spinal cord injury (SCI) due to a stab wound. This resulted in T6 incomplete paraplegia. She trialed the ReWalk System. The enrollee is currently unable to ambulate due to incomplete lower extremity paresis and is relegated to prolonged sitting due to the absence of capable products and treatments which can help restore her walking abilities. She has lower extremity spasticity that interferes with her sleep and with her safety during transfers. She is at risk for secondary medical complications associated with chronic sedentary behavior and spinal cord injury.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 spinal cord injury, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY