Diskectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cervical spine surgery (artificial disc replacement at C4-5 and C5-6 and foraminotomy with anterior cervical discectomy and fusion (ACDF) at C7-T1). Findings: The physician reviewer found that Boddapati and colleagues have noted that many patients with multilevel disease are not good candidates for cervical disc arthroplasty (CDA) at all levels. For such patients, hybrid surgery, a combination of adjacent anterior cervical discectomy and fusion (ACDF) and CDA, may be more appropriate. They concluded that patients undergoing hybrid surgery are not at increased risk of perioperative complications relative to a 2-level ACDF and may benefit from shorter length of stay.

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for L4-5 artificial disc replacement. Findings: The physician reviewer found that there is sufficient support for the requested services in this patient’s case. The U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that this device is indicated for spinal arthroplasty in patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. FDA exclusions include bony lumbar spinal stenosis and isolated radicular compression syndromes, especially due to disc herniation.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total disc arthroplasty procedure. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for treatment of up to two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.

Physician 1: The patient is a 26-year-old male with a history of low back pain and radicular symptoms to both legs, dating back to 2001. Conservative treatment had not been effective. MRI showed disc protrusions at L4-5 and L5-S1, but no frank nerve root compression and no clinical neurological deficits were described. Two-level endoscopic discectomy/thermal annuloplasty at L4-5 and L5-S1 was recommended by the patient’s provider and carried out In March 2006. The patient requested reimbursement from the Health Plan for the costs incurred. The Health Plan denied the patient’s request stating that percutaneous techniques for lumbar, thoracic or cervical discs, with or without endoscopic guidance, are considered investigational and were therefore not a covered benefit.

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 Diskectomy, then check the rights and deadlines that apply to your plan.