Lumbar Artificial Disc Replacement denials: what the review data shows
Independent reviewers have decided 16 published cases where an insurer denied Lumbar Artificial Disc Replacement — and they overturned the insurer 0% of the time. A denial for Lumbar Artificial Disc Replacement is a starting position, not a final answer.
Conditions behind lumbar artificial disc replacement denials
| Category | Decisions | Overturned |
|---|---|---|
| Degenerative Disc Disease | 5 | 0% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 11 | 0% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 0% |
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for low back surgery consisting of lumbar artificial disc – single interspace level L4-5. Findings: The physician reviewer found that available records indicate that this patient is being treated for lumbar disc degenerative disease with chronic bilateral low back pain with lower extremity pain, numbness, and burning. The patient underwent a discogram which yielded no relief. The patient’s recent physical examination revealed symmetric range of motion within normal limits, with intact strength, sensation, and reflexes. However, the patient’s dual energy x-ray absorptiometry (DEXA) scan showed spine and hip impressions of moderate osteopenia with a T-score of -1.6, which was decreased from -1.7 on the previous study. The U.S.
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for lumbar spine disc replacement surgery and in-patient hospital services. The enrollee has a long-standing history of low back pain. He has a history of a L4-L5 left micro discectomy. He underwent micro-discectomy for a herniation of the nucleus pulposus. The enrollee had a reduction of low back pain after the procedure, but it returned and it was worse. He has had physical therapy, nerve blocks, epidural injections, acupuncture, and radiofrequency facet denervation. These treatments were ineffective. The enrollee underwent an anterior lumbar approach discectomy at L3-L4-L5; followed by placement of the M6 lumbar artificial discs at both levels.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Lumbar Artificial Disc Replacementwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY