Thoracic Spine Pain denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving thoracic spine painand overturned the plan’s denial in 33.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
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. | 15 | 33.3% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 33.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the middle spine and/or right knee. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of chronic knee pain, for an adult patient with initial radiographs demonstrating degenerative changes, an MRI may be appropriate as the next imaging examination, if the patient's symptoms are not explained by the radiographic findings. In this case, the patient’s pain persists despite conservative management and were not explained by radiographic findings. Therefore, an MRI is appropriate, and he may be a surgical candidate.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic facet joint radiofrequency neurolysis. In this case, the patient presents with chronic thoracic spine pain which responded to two medial branch blocks, with 80% pain relief for six to eight hours, which is the expected duration of the joint blocks. Based on the patient’s response, there is level 3 evidence to support proceeding with radiofrequency ablation to treat the affected thoracic levels.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for thoracic facet joint injection and transforaminal lumbar epidural steroid injection. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s thoracic and lower back pain. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The current medical evidence does not recommend facet joint injections in the thoracic spine, as there is limited research on therapeutic blocks or neurotomies in this region. Per the medical evidence, therapeutic epidural steroid injections are recommended as a possible option for short-term treatment of radicular pain with use in conjunction with active rehabilitation efforts.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of thoracic spine without contrast material. CT scans are performed with high dose radiation and are not without risk. Findings: The physician reviewer found that A CT scan of the thoracic spine could expose the patient to up to 100 times the amount of radiation of an x-ray. CT of the thoracic spine may be indicated in cases with highly suspected thoracic spine pathology, calcified disc herniation with symptoms of myelopathy, suspected tumor, infection, or trauma, or assessment of spinal deformity and surgical planning. The patient does not meet these indications based on the submitted records. In this case, the submitted records do not show that the patient’s pain is of a long duration enough to suspect a more serious pathology.
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 thoracic spine pain, 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