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

The enrollee is requesting authorization and coverage for home wax bath kit/portable paraffin bath unit.  The enrollee has a past medical history of herniated intervertebral disc, status post discectomy, and was seen for joint pain that had been ongoing. The enrollee initially noticed the pain in her right middle finger at the distal interphalangeal (DIP) joints and thought it was due to trauma. The pain initially subsided, but it never went away and eventually progressed to her right wrist, as well, which felt very tender. She also felt tenderness at times in her left hand/wrist. Her physician ordered an x-ray, which was negative. Laboratory test results indicated antinuclear antibody (ANA) was positive, C-reactive protein (CRP) level was nine and erythrocyte sedimentation rate (ESR) was within normal limits. She was diagnosed with lupus and was further evaluated by a rheumatologist. The plan included paraffin wax treatment to increase tissue elasticity prior to manual therapy/therapeutic procedures to bilateral hands. A paraffin bath was prescribed. Paraffin wax bath is a reasonable treatment modality for this enrollees clinical condition.  A paraffin bath is a superficial heat modality commonly used for treating small joint pain and improving mobilization secondary to arthritic conditions. This treatment was prescribed by the enrollees physician as indicated in an office visit note. There is also a therapy note dated documenting the provision of paraffin wax therapy.  Paraffin wax treatment is widely used as a physical therapy method for the treatment of hand-related diseases, such as rheumatoid arthritis, osteoarthritis, and carpel tunnel syndrome (CTS). Studies have shown that paraffin wax bath treatment was more effective and efficient at raising the tissue temperature to higher temperatures and maintaining the high temperature longer than when compared to traditional dip and wrap method, hot fomentations, wet heat, shortwave diathermy (SWT) and ultrasound. According to the medical literature, wax applications to the hands of people with rheumatoid arthritis (RA) were able to facilitate hand exercises with no detrimental effects attributable to its effect on hand tissue temperatures. A study indicates the benefit of paraffin treatment in conjunction with splinting to enhance the functional recovery of the hand related to carpel tunnel syndrome (CTS). Based on the medical literature, paraffin treatment is commonly used for heat therapy to relieve pain, joint stiffness, muscle spasm and increase collagen extensibility, blood flow, improved healing, and to aid in the resolution of inflammatory infiltrates, edema, and exudates. Due to its thermotherapy effect, paraffin wax bath therapy is commonly used in conjunction with physical therapy to enhance hand functionality and the effectiveness of physical/occupational therapy on improving hand arthralgia and movement. This enrollee has hand arthralgia/arthritis associated with lupus. Similar to rheumatoid arthritis (RA), lupus is an autoimmune disease that causes inflammation in the joints. Based on the mechanism of action of paraffin wax bath therapy on the hand, it is considered the beneficial effects of paraffin wax bath on the hand functionality of patients with RA will also be beneficial to this enrollee with lupus. Considering enrollees refractory hand pain and functional limitations with medication alone, the medical necessity for multimodal therapy that includes paraffin wax bath therapy is supported.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation and 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 similar medical condition.