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

Physician 1: The patient is a 64-year-old woman who sustained a clavicle fracture in May 2004. At the time the patient was evaluated by an orthopedist union was not yet established and osteopenia was noted. A bone growth stimulator was recommended. The Health Plan indicates a bone growth stimulator is considered investigational for treatment of patients such as this patient. Bone growth stimulators are of proven efficacy and have been used with great success over the past twenty years. As the patients provider indicates, the only other treatment option for this patient who was at eight weeks from date of injury with no obvious callus formation or union, would have been surgery, plating and bone grafting of the fracture. Use of a bone growth stimulator was medically appropriate and necessary to attempt union of the patients fracture. It was more beneficial than surgery with significantly less risk. Therefore, I have determined that the equipment at issue was 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 64-year-old female with a fractured clavicle that occurred in May 2004. In July 2004, the patients provider recommended use of a bone growth stimulator due to non-union of the fracture. After a two-month trial of bone growth stimulation therapy, the patients physician noted improvement. The Health Plan has denied coverage for use of the bone growth stimulator on the basis that it is considered investigational in this clinical setting. The bone growth stimulator was ordered approximately eight weeks after the patient sustained a clavicle fracture. The patient began bone growth stimulation therapy before there was sufficient time to establish if non-union had occurred. The indications for bone growth stimulation were not met as the therapy was initiated only eight weeks from the date of injury. Thus, the use of bone growth stimulation therapy was premature in this case. As such, I have determined that the equipment at issue was 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 64-year-old female who sustained a fractured clavicle in May 2004. In July 2004, her physician noted the presence of significant deformity and crepitus and no callus formation. The patient began using a bone growth stimulator per her physicians recommendation. The Health Plan has denied coverage for the bone growth stimulator on the basis it is considered investigational for patients such as this patient. Two months of standard treatment of a clavicle fracture in a 64-year-old patient is ample time in which to observe callus formation and decreased crepitus. The clinical findings suggest the patient had delayed union. Use of a bone growth stimulator was medically reasonable and appropriate for this patient and was likely to result in a better clinical outcome than continuation of standard therapy. As such, I have determined that the equipment at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.