Spondylolisthesis denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for back surgery (including CPT codes 22558, 22585, 22612, 22614, 22842, 22845, 22853, 49010, 20936, 20931, and 76000). Wood and colleagues recommended that fusion should be considered for patients with low back pain and isthmic spondylolisthesis who have failed non-operative treatment. Researchers support surgery for spinal stenosis in patients who do not improve with conservative treatment. The authors noted that the inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. Studies 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 refractory to nonsurgical care in the setting of disc degeneration.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for surgical and related services provided. Findings: The patient presented with complaints of persistent low back pain radiating into the enrollee's right buttocks. Enrollee was having difficulty bending down and getting out of a chair. Patient reports that up to two weeks ago, enrollee was working out two times a week with a trainer, running, playing golf and doing well. Enrollee reported an onset of pain after playing golf and was unable to get out of bed the next morning. Enrollee saw chiropractor and was adjusted with no significant relief. Physical examination documented limited right lumbar lateral flexion, tenderness over the sacroiliac joints, right greater than left, and soreness over the sciatic notch. There was no marked lumbar spine tenderness.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Premia total posterior spinal arthroplasty (TOPS) system surgery.The patient is noted to have a history of lower back pain and lower extremity radiculopathy. The patient obtained imaging studies including x-rays and MRI scans. The patient’s MRI of his lumbar spine on 07/18/23 showed evidence of Schmorl's node with Modic type II changes seen in the endplates at L4-5. The study also indicated bilateral spondylolysis with generalized disc protrusion seen at L4-5 and spondylolisthesis of L4 over L5 with severe narrowing of the neural foramina seen on both sides and compression of the bilateral exiting nerve roots. The records provided for review establish a spondylolisthesis of 7.1 mm, which is more than grade 1.

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