Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 42-year-old female with chronic discogenic low back pain secondary to internal disc derangement at L4-5 and L5-6. The patient underwent provocation discography on 8/17/04 demonstrating diffuse annular disruption at L4-5 and midline radial fissure at L5-6. The patients provider has recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan indicates the requested procedure is considered experimental and has not been established as more effective than available standard therapies.Review of the submitted clinical information indicates the patient is not a candidate for microdisectomy, fusion or chemonucleoplasty. In addition, the patient has not had significant relief from other treatments utilized such as medications, epidural injections, and facet joint block injections. Based upon the information provided, the patient is an appropriate candidate for IDET. The articles cited above indicate a significant percentage of the patients who underwent IDET were able to function at a higher level following the procedure. It is not likely that further attempts at standard therapies will be successful in this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 42-year-old female with a lengthy history of chronic discogenic low back pain. She has undergone conservative treatments with no long-term benefit. The patient would like to undergo intradiscal electrothermal therapy (IDET), which is considered investigational by the Health Plan.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of low back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3The patient is a 42-year-old woman with chronic low back pain. Conservative treatments including medications, physical therapy, rehabilitation and facet blocks were unsuccessful. A discography demonstrated a two-level positive discogram. The patient wishes to undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied the patients request on the basis that IDET is considered investigational for treatment of the patients medical condition.Review of the information provided indicates the patient is an appropriate candidate for an IDET procedure. In this case, IDET is likely to be of greater benefit than any standard or non-attempted treatments. A randomized, placebo-controlled trial by Pauzd, et al. demonstrated the superior efficacy of IDET to placebo in chronic discogenic low back pain. Given the failure of multiple standard therapies, IDET is likely to result in a better clinical outcome than continued attempts at standard therapies. As such, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.