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

Physician 1The patient has neuropathy possibly from a B12 deficiency. The patients reported symptoms include bilateral foot coldness and pain and sleep disturbance. The patient also has a non-healing ulcer at the dorsum of the left foot. The patients provider recommended Anodyne therapy, which the patient has undergone with reported benefit. She has requested authorization and coverage for home Anodyne therapy. The Health Plan has denied her request indicating that Anodyne therapy is considered investigational.The Health Plans denial should be upheld. Though the patient has been diagnosed with 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 62-year-old female with foot pain and neuropathy under the care of a podiatrist who has recommended Anodyne therapy. The patient reports substantial improvement after initial Anodyne therapy. She has requested authorization and coverage for home Anodyne therapy. The Health Plan has denied the patients request indicating that Anodyne therapy is considered investigational.This patient is reported to have neuropathy from a B12 deficiency. There is no information in the provided documentation to determine the history of her condition or to understand the underlying etiology. A comprehensive neurologic evaluation is the first step in evaluating this patient for effective therapy. Furthermore, review of current medical literature demonstrates that Anodyne therapy has not been systematically studied. Thus, there is insufficient data establishing the long-term efficacy of Anodyne therapy. 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 3The patient is a 62-year-old woman with a history of peripheral vascular disease and neuropathy, apparently related to a B12 deficiency. Additionally, the patient has a non-healing ulcer at the dorsum of the left foot measuring approximately .24cm in diameter. The patients podiatrist recommended Anodyne therapy. The patient indicates that initial Anodyne therapy has been beneficial. She has requested authorization and coverage for home Anodyne therapy. The Health Plan has denied the patients request indicating that Anodyne therapy is considered investigational.Based upon the submitted information, it does not appear that a comprehensive workup of the patient has been performed. The history of the patients condition is not known and the etiology is not clear. Though it appears the patient has benefited from initial Anodyne therapy, there is insufficient information regarding the patients use of 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.