Cervical Artificial Disc Replacement denials in California external review
In the California DMHC record, independent physician reviewers decided 26 published external-review cases involving Cervical Artificial Disc Replacementand overturned the plan’s denial in 7.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Cervical Artificial Disc Replacement denials
| Category | Decisions | Overturned |
|---|---|---|
| Cervical Radiculopathy | 7 | 14.3% |
| Cervical Spondylosis | 6 | 0% |
| Cervical Degenerative Disc Disease | 4 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 19 | 5.3% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 7 | 14.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for insertion of artificial intervertebral disc for treatment of the enrollee’s neck pain. Findings: Two physician reviewers found that the North American Spine Society state that cervical artificial disc replacement “may be indicated for the following diagnoses with qualifying criteria, when appropriate.” The guidelines include “radiculopathy related to nerve root compression from one or two-level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain that has been refractory to medical or non-operative management” or “myelopathy or myeloradiculopathy related to central spinal stenosis from one or two level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-4 to C6-7 with or without neck pain.” In t…
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial disc replacement. In the medical literature, researchers reported on artificial disc placement in the cervical spine and found the device maintained physiological segmental motion at 24 months after implantation and was associated with improved neurological success, improved clinical outcomes, and a reduced rate of secondary surgeries compared with ACDF. This patient requires a decompression at the level of adjacent degeneration at C4-5 following ACDF. Moreover, there is adequate data that total disc replacement is superior to ACDF in this clinical setting. Accordingly, the requested artificial disc replacement is medically necessary for treatment of this patient’s intractable neck and right upper extremity pain.
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 a cervical artificial disc replacement (C5-6 and C6-7 with the Simplify implant). This patient’s treatment plan includes C5-6 and C6-7 artificial disc replacement with the Simplify implant. The U.S. Food and Drug Administration (FDA) notes that Simplify indications for use include that the patient should have failed at least six weeks of nonoperative treatment or demonstrated progressive signs or symptoms despite non-operative treatment prior to implantation.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a cervical artificial disc replacement surgery. Bono and colleagues note that according to guidelines for cervical artificial disc replacement (ADR) by the North American Spine Society, cervical ADR may be indicated for patients with radiculopathy related to single level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-C4 to C6-C7 with or without neck pain that has been refractory to conservative treatment, and for single level degenerative disease (either herniated disc or spondylotic osteophyte) from C3-C4 to C6-C7 with or without neck pain that is severe enough to warrant surgical intervention.
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 treatment 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 Cervical Artificial Disc Replacement, 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