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

Physician 1: The patient is a 21-year-old male with a lumbar disc herniation at the L2-3 level.  His condition is described as stable with lower back, buttock, and right leg pain.  He reports his pain as moderate and tolerable.  He has not been able to return to his usual activity level and corrective surgery consisting of decompressive laminotomy and discectomy was recommended. Lumbar traction was discussed and the patient requested a referral.  He consulted with a chiropractic office and VAX-D treatments ensued.  Approximately 30 sessions were provided with apparent positive results.  The Health Plan has denied the patients request for reimbursement based upon their determination that the therapy was experimental/investigational for treatment of a herniated disc.At this time, a review of current literature fails to provide sufficient supporting evidence that VAX-D lumbar decompression is more beneficial than other forms of traction or standard forms of therapy. The patient is likely to experience greater benefit from conventional modalities. Therefore, I have determined that the therapy at issue was/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 2: The patient is a 21-year-old male with a focal disc herniation at L2-3.  He has moderate back, buttock, and leg pain with activity.  Conservative treatment has not been effective and he is a probable candidate for surgical intervention.  In the meantime, he was referred for lumbar decompression using VAX-D. The therapy is considered experimental/investigational by the Health Plan and the patients request for reimbursement was denied.    Multiple studies on traction have not demonstrated efficacy in relieving symptoms due to herniated discs.  Furthermore, claims that the VAX-D decompresses the disc have not been substantiated, as demonstrated by their removal from the VAX-D product literature.  Randomized controlled studies do not show superiority of VAX-D traction when compared to standard treatment modalities for back pain.  At this point in time, the use of VAX-D traction remains investigational in the treatment of a herniated disc.  Based upon the information set forth above, I have determined that the therapy at issue was/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 3: The patient is a 21-year-old male with low back, buttock and leg pain due to a herniated disc at L2-3.  He failed earlier conservative treatments, but apparently was not ready for decompressive laminotomy and discectomy.  He asked for a referral for lumbar traction using the VAX-D and is now requesting reimbursement and prospective authorization for the therapy.  The Health Plan denied his request indicating the therapy was/is experimental/investigational for the treatment of his medical condition.The Health Plans denial should be upheld. VAX-D therapy is an unproven modality in the treatment of lower back pain caused by a herniated disc. There are no peer-reviewed, controlled trials demonstrating the efficacy of VAX-D therapy for this type of pain. Furthermore, VAX-D therapy is not consistent with the standard of care for the treatment of a herniated disc within the medical community. Therefore, I have determined that the therapy at issue was/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.