CNS Extracranial Autonomic 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 suprascapular and axillary nerve radiofrequency ablation. A systematic review indicates that radiofrequency-based interventions targeting shoulder innervation can reduce chronic shoulder pain and improve function. Randomized trial data further show that applying radiofrequency energy to the suprascapular nerve distribution can provide clinically meaningful analgesic benefits compared with injection-based approaches in chronic shoulder pain populations. Prospective evidence also shows meaningful improvements in pain and function in appropriately selected patients with low rates of serious complications over follow-up.

Findings: The physician reviewer found that a patient has requested authorization and coverage for Intracept procedure performed at the L5‑S1 vertebrae. The patient presents with a history of axial low back pain and has trialed physical therapy, medication, and home exercises without improvement. The patient previously tried and failed diagnostic medial branch blocks followed by radiofrequency ablation (RFA). A magnetic resonance imaging (MRI) of the lumbar spine revealed Modic changes at L5‑S1. Medical literature reports improvement in pain and function, including reductions in visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, in patients undergoing basivertebral nerve (BVN) ablation.

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 the Intracept procedure for the back at L5-S1. A study found that patients treated with basivertebral nerve (BVN) ablation showed significant improvement in pain and visual analog scale (VAS), which was sustained out to five years. One study reported improved Oswestry Disability Index (ODI) and pain scores with BVN at the three month endpoint. Another study similarly reported improved VAS and ODI in patients who underwent BVN ablation. In addition, the American Society of Pain and Neuroscience (ASPN) guidelines note that BVN ablation has received a Level A grade for high certainty that the net benefit is substantial in appropriately selected patients.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the Intracept procedure. The medical literature reports significant benefit in pain and function with basivertebral nerve ablation (the Intracept procedure) for patients with axial back pain without radiation. In this case, the record establishes that the patient has a significant history of lower back pain with additional radicular pain. A review of the records establishes repeated mention of the patient’s radicular and sacroiliac pain. Vertebrogenic pain is very specifically axial low back pain without radiation. Additionally, there is no mention of symptoms consistent with vertebrogenic pain, such as worse axial pain with sitting and bending.

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 CNS Extracranial Autonomic, then check the rights and deadlines that apply to your plan.