Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

ature of Statutory Criteria/Case Summary: The patient is a 53-year-old female diagnosed with complex regional pain syndrome (CRPS) involving the left foot. Findings:  The physician reviewer found that the patient underwent left gastrocnemius tendon recession, left foot subtalar arthrodesis, left first ray bunionectomy, left fifth toe hammer toe surgery, and left navicular resection with tendon interposition. A report dated 1/31/19 noted that the patient developed compartment syndrome a few days after the surgery and was treated in the emergency department and discharged. When her cast was removed, she developed severe post-operative pain, sensitivity to cold, touch, numbness, and inability to bear weight on the left foot that gradually worsened to the extent that she was unable to walk. The patient has tried and failed multiple medications, including Percocet, Dilaudid, Elavil, Effexor, Cymbalta, gabapentin, Lyrica and Nucynta. She has undergone three lumbar sympathetic nerve blocks with no improvement in her symptoms. The patient completed a three-day ketamine infusion in September 2017 with 100% relief of hand pain for two to three days. Some decreased foot pain was reported. The patient underwent an additional five-day ketamine infusion in January 2018. On day two the infusion was discontinued due to the patients intolerance, causing tearfulness. The patient completed a 10-day ketamine infusion in February 2019, which provided one week of significant pain relief before a loss of efficacy. The patient has requested coverage for five-day ketamine infusions. The Health Plan denied the request and reported that five-day ketamine infusions were not medically necessary for this patient. At issue in this case is whether five-day ketamine infusions are medically necessary for treatment of this patients medical condition. There is evidence that a course of intravenous ketamine may be effective for CRPS-related pain. The effects did not appear to be sustained beyond four to 11 weeks post-treatment (OConnell, et al.). Randomized trials and several cases of repeated ketamine infusions for patients with CRPS identified concerns about the risks of this treatment, including drug-induced liver injuries that have not been adequately addressed (Dworkin, et al.). Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range.  For treatment of CRPS, there is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks. With regard to frequent infusion treatments with higher doses, there is moderate evidence to support higher dosages of ketamine over longer time periods, and more frequent administration, for chronic pain. A series of infusions should be administered based on patient response (Cohen, et al.). In this case, the patient has undergone three separate infusion series with ketamine. The first one in September 2017 for three days, which provided two to three days of hand pain relief and marginal improvement in the left foot and ankle pain. The patient was scheduled for a five-day ketamine infusion in January 2018 but had to discontinue the infusions due to intolerance. The patient underwent 10-day ketamine infusions in February 2019, providing one week of significant pain relief before a loss of efficacy. The patient did not reportedly receive the duration of benefit recommended in the guidelines for ketamine infusion for chronic pain of three to six weeks (Cohen, et al.). The medical evidence does not support the requested treatment in this clinical setting. Therefore, five-day ketamine infusions are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with a subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.