Spinal Stenosis denials in California external review

What the reviewers wrote

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for removal of posterior segmental instrumentation, arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2, arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace, arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar, and exploration of spinal fusion with other approved services.

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested reimbursement for (1) total disc arthroplasty and (2) one-day hospital stay. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for the treatment of up to two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for disc replacement surgery (L5-S1). Researchers state, “Long-term evidence supports lumbar total disc replacement as safe. The next-generation activL Artificial Disc is more effective at preserving range of motion than first-generation lumbar TDRs (ProDisc-L and Charité) and offers a higher safety profile. Other primary and secondary outcomes are similar between disc designs.” Researchers report in a meta-analysis on the treatment of patients with degenerative disc disease that at two years, total disc replacement was demonstrated to be more beneficial for patients compared to lumbar fusion in Oswestry Disability Index (ODI), Visual Analog Score (VAS), patient satisfaction, the percentage of using narcotics, overall success rate, the rate of patients choosing the same surgical treatment agai…

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