Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Spinal Cord Stimulator Trial
The insurer denied the Spinal Cord Stimulator Trial.
The determination is upheld.

The patient has chronic low back pain. Diagnoses include lumbar intervertebral disc degeneration, lumbar intervertebral disc displacement, lumbar radiculopathy and lumbar spinal stenosis without neurogenic claudication. Records show that the provider requested approval for a spinal cord stimulator trial, which was denied by the health plan as the plan requires that the patient have failed low back surgery, pain from lower limb ischemia, or complex regional pain syndrome and the patient does not have any of these conditions.
A letter of appeal from the treating provider states they are appealing the denial of prior authorization for spinal cord stimulator trial stating that this therapy is the most appropriate. The provider states the patient has had back pain for many years and has been in pain management for many years where she has tried multiple types of conventional treatment such as injections and physical therapy which no longer provide adequate relief. The patient has not had any prior spine surgeries for the pain. She was evaluated by a neurosurgeon and is not a candidate for spine surgery and was recommended for a spinal cord stimulator trial. It was stated the patient underwent psychological clearance and the patient's pain is physical not psychological. The provider states there are limited treatment options for chronic back pain patients who have failed conventional measures.
A letter of appeal from the patient  states that the patient sustained an injury on the job as well as a car accident and her spine has deteriorated with many herniated discs. She reports one is affecting her legs making it difficult to walk, sit or stand for too long and the most she can stand or sit is 20 to 30 minutes. She is in excruciating pain if she stands or sits longer. She reports having no social life. She cannot stand longer than 30 minutes or she starts feeling nerve pain down the legs and reports she can only work for about one week at a time and then quits because of the unbearable pain and when it comes to laundry and cooking she needs her mother's help and reports it has affected the quality of her life.
Magnetic resonance imaging (MRI) of lumbar spine revealed thoracic (T) 12-lumbar (L) 1 left paracentral herniation compressing the ventral thecal sac; L1 - L2 decreased left paracentral herniation; L2-L3 decreased right paracentral herniation; L5 - sacral (S)-1 unchanged broad-based posterior herniation.
On initial consultation, the patient was seen regarding chronic back pain from a motor vehicle accident. She has had multiple treatment options including epidurals. She had a recent epidural. She states she had minimal pain relief with different medications and has had physical therapy on and off for many years as well as interventional procedures. Medications include methamphetamine, Minipress, and Hiprex.  Physical examination revealed pain with lumbar range of motion. It was stated that the patient had a change in sensation in the left lower extremity not further described. There was 4/5 motor strength in the bilateral lower extremities with some mild breakaway weakness. They discussed that the epidural steroid injection performed the prior month was in the lower lumbar spine. The provider recommended a trial of T12-L1 transforaminal epidural injection, noting that her MRI shows a new disc herniation compressing on the thecal site at T12-L1 but she would like to wait and is asking for a surgical consultation.
A surgical consultation noted that the patient has chronic lumbar radiculopathy and an MRI does not show structural pathology and she is not a candidate for surgical intervention at this time. It was felt she would be a good candidate for a trial of spinal cord stimulation for pain control.
A psychological evaluation noted there were no significant psychosocial factors that predict poor response from the patient to undergo a spinal cord stimulator trial.
At issue is the medical necessity of a trial for spinal cord stimulator.
The requested health service/treatment of Trial for Spinal Cord Stimulator is not medically necessary for this patient. Records provided indicate the patient has chronic low back pain with radiculopathy as a result of a motor vehicle accident. It was stated the patient has undergone conservative treatment including medications, physical therapy, as well as injections. The patient recently had a lumbar epidural injection, however, it appears that this was at the lower lumbar level and the treating provider notes a new disc herniation impressing on the thecal sac at T12-L1. The provider recommended the patient undergo an epidural steroid injection at that level, but the patient wanted to hold off in favor of a surgical consultation. It was determined the patient was not a surgical candidate. The provider is now requesting approval for a spinal cord stimulator trial. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Conditionally recommended for the treatment of failed back surgery with persistent leg pain, as salvage treatment for patients who have failed conservative treatment for chronic radicular or complex regional pain syndrome, or for neuropathic pain in post-spinal surgery patients...spinal cord stimulators (SCS) are not recommended for the following indications: Not recommended for radiculopathy in patients who have not undergone spinal surgery and remain candidates for surgery. Not recommended for axial back pain in patients who have not undergone spinal surgery...pinal cord stimulators (SCS) are seen as a therapy for patients suffering primarily from neuropathic pain for which there is no alternative therapy." However, this treatment is only recommended when specific criteria are met for the treatment of complex regional pain syndrome, failed back surgery syndrome or back pain with radiculopathy/primarily neuropathic pain that has failed all other treatments and the patient is not a surgical candidate. The patient has chronic back pain with primarily neuropathic pain in the legs and has failed some conservative treatments, however, the provider had made other valid treatment recommendations that have not been completed yet including injections to address the disc herniations at other spinal levels that are likely pain generators.
Therefore, medical necessity is not established.