Total Disc Arthroplasty denials in California external review
In the California DMHC record, independent physician reviewers decided 22 published external-review cases involving Total Disc Arthroplastyand overturned the plan’s denial in 13.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Total Disc Arthroplasty denials
| Category | Decisions | Overturned |
|---|---|---|
| Degenerative Disc Disease | 4 | 50% |
| Cervical Spondylosis | 4 | 0% |
| Cervical Degenerative Disc Disease | 3 | 33.3% |
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. | 14 | 0% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 8 | 37.5% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for total disc arthroplasty. Lumbar total disc replacement (arthroplasty) is a good surgical option for relatively young patients with discogenic low back pain, with or without radiculopathy, which is limited to one or two spinal levels, as approved by the U.S. Food and Drug Administration (FDA). Lumbar total disc replacement is more suitable for patients with discogenic lumbar pain without significant spinal canal stenosis, facet joint arthritis or spinal instability. Multiple studies have demonstrated the non-inferiority of lumbar disc replacements compared to fusion in terms of clinical outcomes and back pain relief, while maintaining normal vertebral disc mobility compared to lost motion associated with fusion.
Findings: The physician reviewer found that The patient has requested reimbursement for the total disc arthroplasty of the C5-6 and C6-7 cervical vertebrae performed on 12/13/22. A study demonstrated that arthroplasty following ACDF improved patient outcomes with low rates of complications. Additionally, arthroplasty was found to confer similar benefits in the treatment of patients with adjacent segment disease after previous ACDF. This patient’s records suggest concordant foraminal stenosis and degenerative disc disease, which supports an indication for total disc arthroplasty. The records document that the patient developed adjacent segment disease after ACDF, which was performed to treat traumatic instability. The patient reportedly failed months of conservative management including extensive physical therapy, but the patient continued to experience progressive symptoms.
Where the denial was upheld
Findings: The physician reviewer found that the patient has requested reimbursement for (1) total disc arthroplasty and (2) one-day hospital stay. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for the treatment of up to two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total disc replacement procedure [(laminectomy, facetectomy and foraminotomy, unilateral or bilateral with decompression) and (total disc arthroplasty (artificial disc))] at L5-S1. The U.S. Food and Drug Administration (FDA) has approved ProDisc-L total disc replacement for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) for up to two consecutive levels from L3 to S1. The FDA further notes that the patient should be skeletally mature with no spinal growth remaining, have a condition in which pain is caused by wear-and-tear on a spinal disc at one or two consecutive levels in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level(s), and have failed at least six months of conservative treatment.
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 Total Disc Arthroplasty, 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