Neurosurgery Proc denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for neurolysis of bilateral supraorbital and supratrochlear nerves. Findings: The physician reviewer found that Bink and colleagues note that the results from surgical treatment of neuralgia headaches are promising, reporting that in a systematic review, total elimination of symptoms varied between 8.3 and 83 percent. While this is a wide range, the authors noted that the number of patients with improvement of their symptoms was very high. The authors further noted that nerve decompression surgery is an effective way of treating headaches in a specific population of patients with neuralgia. Bajaj and colleagues report, “A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for NeuroPace responsive neurostimulation system and inpatient hospital services. While the Health Plan notes that age 18 is the lower limit of candidacy for the NeuroPace responsive neurostimulation system, such a distinction ignores what takes place in brain development. Cortical and subcortical circuitry in the developing brain is well-established by age 16, and without other comorbidities that can impact epilepsy such as traumatic brain injury or brain tumors, there is functionally no difference between age 16 and age 18. While it is true that myelination continues into the third decade of life, this is primarily localized to the prefrontal portion of the brain and thus, irrelevant in this case.

Where the denial was upheld

Physician 1: The patient is a 39-year-old female with a history of work-related low back pain. She is status post two spinal surgeries and has undergone multiple treatment modalities including massage therapy, acupuncture, and myofascial trigger point injections without sustained relief. The patient is maintained on high-dose narcotics for pain control and continues with severe pain, which has a spastic component and is made worse with straight leg raising. Her most recent MRI of the lumbosacral spine in January 2000 demonstrated mild to modest spinal stenosis at L4-5 secondary to a very broad based central and right paramidline disc protrusion and degenerative disc changes at L5-S1. The consulting pain management specialist has recommended an epiduroscopy for evaluation/treatment of the patient’s continued back pain.

Physician 1: The patient is a 63-year-old female with degenerative disc disease. She is status post posterior spinal fusion at L4-S1. Her provider has recommended a disc replacement at L3-4. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Furthermore, there is no evidence supporting the safety and efficacy of artificial disc replacement above a previous two-level fusion.

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