Lumbar Artificial Disc Replacement denials in California external review
In the California DMHC record, independent physician reviewers decided 16 published external-review cases involving Lumbar Artificial Disc Replacementand overturned the plan’s denial in 0%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
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% |
What the reviewers wrote
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 external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Lumbar Artificial Disc Replacement, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY