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

Physician 1: The patient is a 39-year-old female with a history of work-related low back pain. She is status post two spinal surgeries and has undergone multiple treatment modalities including massage therapy, acupuncture, and myofascial trigger point injections without sustained relief. The patient is maintained on high-dose narcotics for pain control and continues with severe pain, which has a spastic component and is made worse with straight leg raising. Her most recent MRI of the lumbosacral spine in January 2000 demonstrated mild to modest spinal stenosis at L4-5 secondary to a very broad based central and right paramidline disc protrusion and degenerative disc changes at L5-S1. The consulting pain management specialist has recommended an epiduroscopy for evaluation/treatment of the patients continued back pain. The Health Plan has denied coverage for an epiduroscopy on the basis it is considered investigational.Epiduroscopy is an invasive procedure that allows direct visualization of the epidural space through a flexible catheter. It can be used to examine internal tissue, release nerve roots from scar tissue and adhesions, and deliver medications or other agents to relieve intractable lumbar pain. Complications from this procedure include direct nerve root injury, dural tear, and macular hemorrhage. A review of the literature indicates more controlled studies are needed to determine the efficacy of this procedure. This patient has chronic lumbar pain presently managed with narcotic therapy. There is no documentation of any nerve conduction studies demonstrating the degree of nerve involvement. In addition, there is no documentation indicating she has had a recent evaluation by neurosurgery to determine if she is a candidate for further surgical intervention (discectomy, laminectomy or fusion). Her most recent MRI from January 2000 demonstrated spinal stenosis and significant disc protrusion at L4-5. The patient should undergo another MRI to delineate any degree of progression. She should be fully evaluated with all conventional treatment modalities prior to pursuing procedures that are not the standard of care at this time. Based upon the information set forth above, 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. Therefore, the Health Plans denial should be upheld. Physician 2: The patient is a 39-year-old female with failed back surgery syndrome. She has failed conservative treatments. The patient has requested authorization and coverage for an epiduroscopy. The Health Plan has denied the patients request on the basis that epiduroscopy is considered experimental for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no evidence-based, peer-reviewed literature demonstrating the efficacy of epiduroscopy in failed back surgery syndrome. As such, the superiority of epiduroscopy to traditional pain management techniques has not been established. The patient is more likely to receive benefit from conventional therapies than from an epiduroscopy. 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 3: The patient is a 39-year-old female who experienced a work-related back injury and has since undergone two spinal surgeries. The surgeries have not been successful in alleviating her severe spastic component. She has tried several modalities such as massage therapy, acupuncture, and myofascial point injections without sustained relief. She has been taking narcotics to manage her pain. Her physician has recommended an epiduroscopy procedure. The Health Plan has denied coverage for the requested procedure indicating it is considered investigational.Epiduroscopy is generally considered only after failure of all other conservative care including, physical therapy, epidural injections, and percutaneous adhesiolysis. Epiduroscopy is an unproven procedure for patients such as this patient. Its use is limited to intractable radicular pain and not sciatic referred pain/low back pain, which is this patients complaint.  Thus, there is no evidence epiduroscopy is likely to be of benefit to this patient. Accordingly, 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.