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

The enrollee is requesting authorization and coverage for physical therapy, consisting of electronic stimulation, cupping, heat, ice, and massage. The enrollee has chronic low back pain that radiates into the gluteal region. The enrollee reports at lateral knee and medial ankle pain that occurs when standing or walking; subsequent to back pain. Her symptoms started while dancing in college. The physical therapy evaluation noted the enrollees symptoms were consistent with extension intolerance and poor lumbar stability/endurance. There was extension hinge at lower lumbar spine with multisegmental extension motion. The enrollee was educated on the plan of care, which included treatment once every two weeks for 12 weeks, a home exercise program, and the use of heat and ice. The physical therapy progress note from shows the enrollee obtained pain relief with the cupping sessions. The enrollee purchased a self-cupping set and was using heat packs. Progress notes indicate the patient has been receiving massage treatments every two weeks, but the medical records do not indicate improvement in the patients condition. This patient was discharged from physical therapy as she no longer had a need for skilled therapy services. The use of passive modalities for this enrollees chronic symptoms is not generally considered medically necessary. There is insufficient evidence in the record as to why these modalities are necessary at this time and insufficient evidence they were ordered by a physician. The medical literature indicates the use of integrative medicine, including cupping, is increasing in the United States. The evidence regarding the effectiveness of such treatments is inconclusive. These procedures do not demonstrate effectiveness beyond six months. Data on maintenance treatments are sparse. A study on the use of neuromuscular electrical stimulation to treat chronic low back pain demonstrates that, after four-weeks of treatment, patients in the neuromuscular electrical stimulation group did not achieve better pain intensity relief than those in the control group. The results of this study did not support the effectiveness of neuromuscular electrical stimulation for patients with chronic low back pain after a four-week course of treatment. Strengthening of certain muscles in the back has been shown to significantly reduce pain for patients with chronic back and neck pain. Lumbar strengthening has been successful because it is a safe exercise, it is ordered based upon a pretreatment evaluation, and it provides objective measurements. However, there is insufficient evidence in the record of objective measures of improvement with this chronic treatment.                                                           Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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.