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

Physician 1: The patient is a 49-year-old male with a history of chronic pain related to fibromyalgia. He did not respond to usual care and was referred for pain management. Under his pain management program, the patient had an excellent response to interferential stimulation therapy. The patient has requested authorization and coverage for a home interferential stimulation unit. The Health Plan has denied coverage for the requested equipment on the basis that inferential stimulation therapy is considered experimental for treatment of the patients condition. Based upon review of the submitted records, an interferential stimulation unit is medically reasonable and appropriate for treatment of this patients chronic pain. The patient has failed standard therapies. The patient and his provider indicate the patient has benefited from interferential stimulation therapy. Therefore, I have determined that the requested equipment 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 49-year-old male who has a long history of fibromyalgia and chronic pain. His pain management physician states the patient has responded well to interferential stimulation therapy. He has been able to exercise and increase his strength training since beginning this therapy. His physician has recommended a home interferential stimulation unit. The Health Plan has denied coverage for the requested equipment on the basis it is considered investigational. There is definitive supporting literature documenting the efficacy of interferential stimulation therapy in the treatment of fibromyalgia. Review of the submitted clinical records reveals the patients condition has improved with interferential stimulation. The patient has been able to increase physical activity and exercise with use of the unit. Furthermore, the patients use of analgesics has decreased since he began interferential stimulation therapy. There is documented evidence the patient has had greater benefit from interferential stimulation therapy than from standard therapy. Therefore, I have determined that the requested equipment 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 3: The patient is a 49-year-old male with a several year history of chronic diffuse pain, said to be fibromyalgia. He has failed to respond to various interventions in the past. He is also noted to have sleep apnea, treated with nighttime CPAP, as well as migraine headaches and irritable bowel syndrome. An evaluation by a pain specialist on 5/17/04 is consistent with fibromyalgia. The patient has received subsequent treatment by chiropractic measures, acupuncture, and interferential nerve stimulation, which have been reported to be very beneficial in reducing the patients pain and medication requirements, and rather strikingly improved his activity levels.A request has been made for a home interferential stimulation unit. The Health Plan has denied the request on the basis that the requested equipment is experimental in nature. Review of the literature concerning inferential stimulation therapy reveals no scientifically meaningful studies to support the use of interferential stimulation therapy; rather, available studies suggest results indistinguishable from those of traditional tens units, or, in some reports, no different than those with placebo. For the most part, available literature concerning the requested equipment appears to be promotional rather than scientific. Though the patient and his provider describe benefit from interferential stimulation therapy, there is no scientific basis supporting the efficacy of the therapy. Therefore, I have determined that the requested equipment 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.