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

Physician 1The patient is an 18-year-old female who has sciatic pain as a result of a fall. A request has been made for sciatic entrapment release and placement of anti-scarring agent. The Health Plan has denied authorization for the requested procedure on the basis that it is considered investigational.Although treatment of piriformis syndrome is somewhat difficult using standard techniques, the requested procedure is without established efficacy. There is no scientific evidence demonstrating the requested procedure is likely to be of any benefit in this case. In the absence of proven beneficial effects there is no indication for the requested procedure. Therefore, I have determined that the requested procedure 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 an 18-year-old female who has persistent sciatic pain after a fall in the bathtub. She has undergone an EMG and MRI of the lumbar spine and pelvis. Upon examination the patient had normal ankle reflexes. The patient had an MRI of sciatic nerve, which showed possible subtle edema. She has been diagnosed with piriformis syndrome. The patients provider has recommended sciatic entrapment release and placement of anti-scarring agent. The Health Plan has denied authorization for the procedure on the basis that it is considered experimental. In the absence of electrodiagnostic or imaging evidence of sciatic dysfunction decompression is unlikely to be of benefit. The MRI suggests some nerve edema, possibly contusion to the nerve. The recommended decompression is unlikely to help. Furthermore, aggressive surgical treatment in cases such as this can lead to an increase in symptoms in some patients. Therefore, I have determined that the requested procedure 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 an 18-year-old female with sciatica diagnosed by magnetic resonance neurography, which demonstrated subtle abnormal increased signal of proximal left sciatic nerve. The course of the nerve is symmetric to the right without gross deviation. X-rays and MRI of the pelvis were within normal limits. An MRI of the lumbar spine was essentially normal. A request has been made for sciatic entrapment release and placement of anti-scarring agent. The Health Plan indicates the requested procedure is considered experimental.Review of the submitted records does not demonstrate that more common causes of the patients pain have been ruled out. The patients EMG was within normal limits. True sciatica should demonstrate absent H-reflex as minimal neurophysiologic pathology. Furthermore, although diagnostic anesthetic blockade is the gold standard it does not appear to have been utilized in this case. Moreover, surgical release is a last resort and should only be pursued once non-operative and conventional treatment has failed. There is no evidence the patient has undergone therapeutic injection therapy, which has documented efficacy in cases such as this. Therefore, I have determined that the requested procedure 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.