Kyphoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 64-year-old man with compression fracture of T9, T12, and L1-3. It has been recommended that the patient proceed with vertebroplasty and/or kyphoplasty because of the failure of conservative treatment. The Health Plan has denied authorization and coverage for the requested procedures indicating that vertebroplasty and kyphoplasty are considered investigational in nature.The patient has attempted conservative measures including rest, medication, and physical therapy, yet he has persistent pain. The submitted medical records demonstrate that the patient is a candidate for vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty have a proven place in the treatment of compression fractures. The procedure devices have been approved by the Food and Drug Administration and numerous reports have shown the efficacy of the procedures.

Physician 1The patient is a 59-year-old female who has an L5 compression fracture with back pain and leg pain that has been unresponsive to conservative treatment. The patient also has end-stage liver failure. The patient’s provider indicates a kyphoplasty for treatment of the patient’s back pain is the least invasive option in light of her end-stage liver disease. The Health Plan indicates the efficacy of the requested procedure has not been demonstrated.This patient has a pathologic fracture of the L5 vertebrae with severe pain. Review of the current medical literature demonstrates kyphoplasty has been shown to be very effective for immediate and lasting pain relief. The patient is more likely to obtain relief from her back pain with kyphoplasty than with any other procedure.

Where the denial was upheld

Physician 1: The patient is a 54-year-old male who has chronic back pain with disc degeneration and chronic multiple compression fractures due to a motor vehicle accident in May 2003. He is requesting authorization and coverage for a kyphoplasty. The Health Plan has denied this request citing the procedure’s lack of proven efficacy in this setting.Kyphoplasty is not likely to be effective in cases of multiple chronic compression fractures and multiple-level degenerative disc disease. Additionally, the patient’s injury occurred in 2003; a kyphoplasty performed three years from the time of injury is not likely to be beneficial. The procedure is considered experimental in this setting involving multiple chronic fractures and severe disc degeneration.

Physician 1This patient is a 37-year-old woman who sustained a compression fracture at L-1 in December 2003 after being thrown from a horse. The patient reports problems with constant pain, although a back brace has provided some benefit. The patient has requested authorization for kyphoplasty. The Health Plan has denied the request indicating that the requested procedure is experimental in nature.The patient is a young woman without osteoporosis. This patient has not tried bracing and has only attempted medical management for a short time. The medical literature suggests that younger persons with compression fractures heal and do very well with bracing for three months. The literature does not support kyphoplasty over conservative management in the patient’s age group.

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