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

Physician 1:  The patient is a 16-year-old female with a history of pelvic/groin pain.  She has migratory pain in the lower abdominal quadrants and groin, right side greater than left.  The pain is constant and always present, but can increase to as high as 7/10.  She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines.  She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present.  She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram. The patient has undergone a trial of physical therapy and acupuncture without success. At issue is whether the biofeedback recommended by the tertiary care pediatric pain management service is medically necessary.  Biofeedback is an alternative complementary treatment for chronic pain in the pediatric population. Review of the relevant literature includes a study that surveyed 43 pediatric anesthesia fellowship programs. They received 100% response from the survey.  Of the 43 fellowship programs, 38 (86%) offered one or more complimentary and alternative medical (CAM) therapies. Sixty-five percent of those programs offering CAM therapy offered biofeedback as an option to their patients.  This is by far the most common CAM therapy offered at these fellowship programs.  Furthermore, there have been some small studies demonstrating success with biofeedback for treatment of migraines and in complex regional pain syndrome, phantom limb pain and pelvic floor pain.  The submitted clinical evidence demonstrates the patients pain is severe. Regional blocks and focal treatments are not indicated in a pain syndrome that is multi-focal (headache, shoulder pain and groin pain).  Given the exhaustive workup to find a cause, the multi-focal nature of the pain, the lack of evidence of significant psychopathology, and the multiple standard medications that have been tried and failed, I have determined that the therapy at issue 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 2:  The patient is a 16-year-old female with chronic pain. Her pain is in the pelvic/groin area with migratory pain in the lower abdominal quadrant. In addition, she has shoulder pain and headaches. Her parent is requesting reimbursement and authorization for future treatment with biofeedback therapy for the patients pain management. The Health Plans denial should be upheld. At this time, the peer-reviewed literature does not provide sufficient evidence to clarify the role of biofeedback in the chronic pain management of adolescents. Further studies are needed before the therapy can be recommended in this clinical setting. Moreover, based on the information provided, other modalities are available that may be more appropriate as a pain management option for patients such as this patient. Accordingly, I have determined that the therapy at issue is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3:  The patient is a 16-year-old female with a history of pelvic/groin pain, abdominal pain, shoulder pain, and chronic headaches, possibly migraines. She has received an extensive workup in the past and has been tried on multiple standard treatment modalities. Biofeedback therapy was recommended by her pain specialist and the patient has shown some benefit from the therapy. A request has been made for coverage for past and future biofeedback sessions. The Health Plan has denied this request citing a lack of peer-reviewed data supporting its efficacy.Review of the clinical information provided indicates the patient has maximized the usual conservative care for her chronic pain without a change in symptoms. Biofeedback therapy has resulted in improvement in the patients symptoms. The use of biofeedback therapy is this particular case is superior to the option of no care or continued standard care. The therapy at issue is medically reasonable and appropriate and should be continued. Therefore, I have determined that the therapy at issue 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.