Charite denials in California external review
In the California DMHC record, independent physician reviewers decided 21 published external-review cases involving Chariteand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Charite denials
| Category | Decisions | Overturned |
|---|---|---|
| Vertebral Disc Prob | 11 | 0% |
| Back Pain | 7 | 0% |
What the reviewers wrote
Where the denial was upheld
Physician 1: This patient is a 35-year-old male who has degenerative disc disease at L4-5 and L5-S1 with resultant disabling back pain. A discectomy performed in 1997 has not provided enduring pain relief. His physician indicated that the patient has tried conservative measures and is unable to relieve his pain. Therefore, the physician has recommended an artificial disc replacement based on the patient’s young age. The Health Plan has denied authorization for the requested procedure on the basis it is considered investigational.To date, there is no long-term data supporting the benefits of artificial disc replacement over more conventional surgical interventions. Additionally, there is a paucity of data on the outcome of multiple disc replacements in general and more specifically when the disc replacements are at non-contiguous levels.
Physician 1: The patient is a 38-year-old female with degenerative disc disease at L5-S1 attributed to lifting a heavy object. The patient’s provider believes the L5-S1 disc is responsible for her pain based upon a discogram performed in August 2005. The patient has been identified as a candidate for artificial disc replacement, but the Health Plan considers this procedure experimental and has denied authorization and coverage.The Health Plan is correct that the requested procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine.
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 Charite, 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