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

Physician 1: The patient is a 50-year-old female with facet arthropathy, spinal stenosis, degenerative disc disease and spinal radiculopathy.  She has had significant pain and underwent facet joint injections and lysis of adhesions to treat her condition.  The patient reported that the procedures were helpful in relieving her symptoms.  She has requested reimbursement and continued authorization and coverage for the facet joint injections and lysis of adhesions. The Health Plan denied her request based upon a determination that the procedures are experimental/investigational in this clinical setting.There is no class I data to support the use of facet joint injection or lysis of adhesions in cases of degenerative lumbar spinal stenosis or disc degeneration. The article by van Tulder and others is a meta-analysis of the recent literature and clearly demonstrates there is no significant data supporting the use of facet joint injections. Additionally, lysis of adhesions is not within the standard of care within the orthopedic community for the treatment of degenerative spinal stenosis.  Therefore, I have determined that the procedures at issue are 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 2: The patient is a 50-year-old woman with a long-standing history of back and leg pain. She has undergone percutaneous lysis of adhesions and facet blocks and reports an improvement in her level of functioning. A request has been made for further treatment with these procedures, but was denied by the Heath Plan due to their experimental/ investigational status.There is little in the way of documentation to establish the clinical efficacy of percutaneous lysis of adhesions. While the patient and her surgeon report success in managing her pain, this is an isolated anecdotal report and not equivalent to a structured clinical trial with peer-reviewed publication.  At this time, there is no evidence the procedure is superior to placebo in the treatment of conditions such as this patients.  Conversely, facet joint injections have been shown to be effective in the treatment of arthritic conditions similar to the patients spinal arthropathy, and may be the mechanism of her symptom relief.   As such, I have determined the facet injections were indicated and likely to be beneficial, but the percutaneous lysis of adhesions was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be partially overturned.Physician 3: This patient is a 50-year-old female with spinal stenosis, degenerative disc disease, and spinal arthropathy who reports immobilizing back pain and leg pain.  She finds that previous treatment with facet joint injections and percutaneous lysis of adhesions has relieved her symptoms and she would like to continue with the procedures.  The Health Plan deemed the procedures experimental/investigational and denied her requests for reimbursement and continued authorization and coverage.Epidural lysis of adhesions is an unproven procedure without established efficacy or generally recognized clinical benefit. Likewise, the therapeutic value of facet joint injections is untested, although they are of some limited benefit as a diagnostic procedure. Both of these procedures remain experimental/investigational for treatment of the patients medical condition and have not been shown to provide clinical benefits beyond those available with traditional therapies.  The Health Plans denial should be upheld.