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

Physician 1:  The patient was a 52-year-old male who had a L1 compression fracture secondary to metastatic cancer and was treated with percutaneous vertebroplasty. According to his family, the surgery was successful and provided the patient with significant pain relief until his death in November 2005. The Health Plan has denied reimbursement for the cost of the procedure. At issue is whether the vertebroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Vertebroplasty is not experimental or investigational. It has been studied extensively and been performed for more than 20 years. There are indications and contraindications established for the procedure. The device utilized has been approved by the Food and Drug Administration. The surgery was medically indicated in this case and was appropriate. It was also successful in providing pain relief to a patient with end-stage cancer. Therefore, I have determined that the procedure 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 was a 52-year-old male who had a L1 fracture from a metastatic tumor. At the time he was admitted to the hospital he was in severe pain. His provider recommended he undergo percutaneous vertebroplasty. The procedure was successful in relieving the patients pain. A request for reimbursement for the procedure has been denied by the Health Plan on the basis that vertebroplasty remains investigational.Review of the submitted clinical information indicates the patient had immediate pain relief with the vertebroplasty. His fracture would not have healed with bracing. Furthermore, the literature supports vertebroplasty for pathologic fractures due to tumor. Accordingly, I have determined that the procedure 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 3:  The patient was a 52-year-old male who was diagnosed with lung cancer in January 2005. In January 2005 he had a left lobectomy followed by chemotherapy and radiation. He developed recurrent DVTs with emboli requiring hospitalization. He was treated with anticoagulation and an inferior vena cava filter. In September 2005 he developed acute back pain. The pain was severe and increased and was incapacitating and not relieved by large doses of narcotic medication. In September 2005 he was taken to the hospital by ambulance and was admitted. An MRI showed a metastatic compression deformity of L1. There was no neurologic involvement. In September 2005 he had a fluoroscopically-guided L1 vertebroplasty. After the vertebroplasty the pain was significantly relieved. The Health Plan has denied coverage for the vertebroplasty indicating it is considered investigational for fracture treatment.The submitted records demonstrate the patient was in a significant amount of pain and continued conservative treatment was not likely to be effective. Vertebroplasty has been shown to provide immediate and lasting pain relief in this setting. The patient was an appropriate candidate for the procedure, and in fact, immediately benefited from the procedure. For these reasons, I have determined that the procedure 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.