Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low Back Pain.
Treatment:  Nerve Treatment in the Spine.

The insurer denied the nerve treatment in the spine.  The health plan's determination is upheld.

The patient is a female who has had chronic lower back pain (LBP) for more than 20 years that is causing a significant impact on her quality of life (QOL) and activities of daily living (ADL's). The patient has a very complicated past medical history (PMH) including hypertension (HTN), myofascial pain syndrome, morbid obesity class II, radiculopathy, sacral joint pain, lumbosacral spondylosis and disc. She also has a medical history of herniations, knee pain, noninsulin dependent diabetes mellitus (noninsulin dependent diabetes mellitus (NIDDM)) hypercholesterolemia, mood disorder, papillary thyroid cancer, obstructive sleep apnea (OSA), sleep inertia, and fibroids. Her past surgical history included, microdiscectomy lumbar vertebrae (L)4-5, bilateral mammoplasty with reduction, gastric bypass and myomectomy.

Her medications included Aspirin, Gabapentin, Metoprolol, Celecoxib, Synthroid, Lexapro, Losartan, Metformin, Simvastatin, Ambien, Ambelz, Iron, Vitamin B12/Vitamin D3, and fish oil. She had no known drug allergies (NKDA) and did not smoke or use alcohol. The patient has used nonsteroidal anti-inflammatory drugs (NSAID's) and Gabapentin for pain.

She has had multiple facet blocks, multiple radiofrequency ablations (RFA's), transforaminal epidural steroid injections (ESI's), trigger point injections, sacroiliac (SI) joint injections, and surgical procedures. It was noted that the ESI's and RFA's did result in some improvements although transient. She describes her pain as a 7 out of 10 as shooting and dull with paresthesias radiating down her left leg to her ankle feet. The pain is worse with standing and activities. The patient review of symptoms was remarkably negative in the pain physician's note including no systemic complaints including fatigue, weakness, weight loss, difficulty sleeping, paroxysmal nocturnal dyspnea (PND), joint pains, dizziness, memory loss, etc. She did note back pain with muscle pain and cramps.

The proposed health service or nerve treatment in the spine is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease. 

With respect to this case the patient appears to have significant pain due to her chronic LBP. The requesting physician notes that the patient's pain is significant and limits her ADL's but there is no Oswestry Disability Index (ODI) score or specific explanation as to the degree of limitations. Furthermore, the pain physician notes Modic changes, although these are not included in the radiologist report included. There appears to be some discrepancies with the patient's weight, which may be from weight loss, but there is also a change in her height. These may be due to measuring errors or transcription errors but are confounding as are the review of symptoms (ROS) and physical exam (PE), which seem incongruent from the patients' complaints. The patient appeared to have some improvements from ESI's and RFA's, which were transient and expected. 

It appears that a significant component of the patient's pain is due to muscle pain/spasm in the paraspinal muscles. Additionally, she is morbidly obese and has already undergone a breast reduction and gastric bypass. She continues to be obese and due to her gastric bypass may have absorption issues (she already takes Iron) and the contribution of both of these to her pain complaints is unclear. As a result, it is difficult to opine on the contribution of many of the diseased anatomic structures/pathology as the etiology of her pain. 

The pain physician noted the patient did not seek consultation due to the Coronavirus (Covid), but a neurosurgeon should evaluate her. Assuming this is done, given this patient has failed multiple other conservative therapies, if she has Modic 1 or 2 changes, her pain continues despite the most recent transforaminal epidural steroid injection (TFESI), surgical options would not guarantee relief or are appropriate at this time, it would be reasonable to consider STIR to improve quality of life and physical limitations if they exist.