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

Physician 1The patient is a 42-year-old male with burning pain in his feet. His diagnosis is listed as peripheral neuropathy. However, there are no neurology notes or exam results included in the information provided. The patient has requested authorization and coverage for Anodyne therapy. The Health Plan has denied the patients request indicating that Anodyne therapy is considered investigational.The Health Plans denial should be upheld. Though the patient has been diagnosed with peripheral neuropathy, there is no evidence that the patients diagnosis has been further qualified. In any event, Anodyne therapy is of unclear benefit. The efficacy of Anodyne therapy has not been established through significant, case-controlled studies. As such, there is no evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities. Therefore, I have determined that the requested therapy 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 2The patient is a 42-year-old male with painful peripheral neuropathy who wishes to be treated with monochromatic near infrared Anodyne therapy. The patient was evaluated by neurologists who made the appropriate diagnosis. However, the cause of the neuropathy has not been defined (as is often the case with this disorder). The Health Plan has denied authorization and coverage for Anodyne therapy on the basis the requested therapy is considered experimental.The literature is replete with treatment modalities for the relief of pain caused by neuropathy. Unfortunately, none of the recommended medications have proven to be effective for this patient. Most medications touted to provide relief of pain and discomfort have been poorly tolerated by the patient (the treatment tends to be worse than the disease). Anodyne therapy appears to have provided a modicum of relief for patients with diabetic neuropathy. Given the failure of standard treatment modalities, a trial of Anodyne therapy is medically reasonable and appropriate. Based upon the information set forth above, I have determined the requested therapy 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. The patient should undergo a three-month trial of Anodyne therapy. If at the end of the three-month trial the patients condition has improved, Anodyne therapy should be continued.Physician 3The patient is a 42-year-old man who has been experiencing burning pain in his feet. The patients provider has diagnosed him with peripheral neuropathy. The patient has requested authorization and coverage for Anodyne therapy for pain relief. The Health Plan has denied the patients request indicating that Anodyne therapy is considered investigational.The Health Plans denial should be upheld. Anodyne therapy is not the standard of care for treatment of peripheral neuropathy. Review of the medical literature regarding Anodyne therapy reveals there is no clinical evidence of established efficacy. Thus, it is not likely that Anodyne therapy will result in a superior clinical outcome compared to standard therapies. Therefore, I have determined that the requested therapy 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.