Spinal Cord Stimulator denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a spinal cord stimulator.A review of current medical literature reveals that there is strong evidence supporting the use of spinal cord stimulation (SCS) for treating chronic refractory back pain with and without radicular features producing clinically relevant outcomes. A study reviewing the efficacy of SCS concluded that “the option of spinal cord stimulation should be considered after conservative therapy has failed”. The authors cited large-scale randomized controlled clinical studies that showed that high-frequency forms of SCS were effective for the treatment of patients with chronic back pain. Further, the authors of another study evaluated the benefits of high-frequency SCS for surgery in patients suffering from back pain.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a spinal cord stimulator. Amirdelfan and colleagues reported on a prospective, multicenter, randomized controlled trial evaluating the long-term quality of life improvement for patients with chronic intractable back and leg pain with the use of spinal cord stimulation. The authors found that of the 171 patients who received a permanent spinal cord stimulation device implant, a higher proportion of patients had marked improvement in their level of disability with moderate to minimal impact on their daily function versus the control group at one-year follow-up.

Where the denial was upheld

The patient has requested authorization and coverage for a spinal cord stimulator. Researchers evaluated the benefits of high frequency spinal cord stimulation for surgery naïve patients with low back pain. The authors reported that their results showed a 50% improvement of low back pain with a mean follow-up of 306 days after implantation. They also concluded that, the option of spinal cord stimulation should be considered after conservative therapy has failed. In this case, the patient has diffuse low back pain with radiation into the right anterolateral thigh and right groin along with a history of multiple falls. The patient’s chronic pain involves the neck, shoulders, fingers, calves and feet. She has magnetic resonance imaging (MRI) results confirming degenerative changes at L3-4 and L4-5 with foraminal narrowing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spinal cord stimulator (CPT 62350) for treatment of her transverse myelitis. Findings: Two physician reviewers found that the requested procedure is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. The patient presents with chronic back pain and lower extremity symptoms. She had an acute neurologic event years ago with residual symptoms. There is no documentation the patient has tried physical therapy, transcutaneous electrical nerve stimulation (TENS), injections, behavioral therapy, or a back brace in the last 24 months. In addition, there is no documentation of an electromyogram (EMG) to rule out peripheral neuropathy for her burning pain.

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 Spinal Cord Stimulator, then check the rights and deadlines that apply to your plan.