Charite denials: what the review data shows

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.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Charitewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.