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

Physician 1: The patient is a 51-year-old female with a long history of back pain. A discogram revealed degenerative changes at L4-L5. There is no documentation of radiculopathy. The patients physician reports the patient has tried and failed multiple treatment modalities including physical therapy, muscle relaxants, and nonsteroidal anti-inflammatory medication. At her physicians recommendation the patient is requesting authorization and coverage for percutaneous discectomy via radiofrequency ablation.Percutaneous discectomy via radiofrequency ablation is a procedure for radiculopathy secondary to continued disc protrusions. This patient has back and coccyx pain without any description of radiculopathy. The use of the proposed procedure in low back pain has not been evaluated in clinical controlled studies. As such, the efficacy of percutaneous discectomy via radiofrequency ablation for treatment of patients such as this patient has not been established. Accordingly, 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 2: The patient is a 51-year-old female who has lumbar degenerative disc disease. The patient has attempted conservative therapies without sustained benefit. She has requested authorization for percutaneous discectomy via radiofrequency ablation. The Health Plan has denied this request on the basis the requested procedure is considered investigational.Percutaneous discectomy via radiofrequency ablation is not standard care for treatment of degenerative disc disease. There are no randomized, controlled trials demonstrating long-term efficacy of percutaneous discectomy. Furthermore, there is no peer-reviewed Class I data to suggest that percutaneous discectomy is a more effective treatment option for this patients condition than standard therapies. 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 3: The patient is a 51-year-old female who has degenerative disc disease at L4-L5. The patient reports standard treatment has not been effective. She wishes to undergo percutaneous discectomy via radiofrequency ablation. The Health Plan indicates the long-term efficacy of the requested procedure has not been established.Percutaneous discectomy via radiofrequency ablation remains an unproven procedure. There is not sufficient peer-reviewed, blinded, controlled data supporting its efficacy. As such, percutaneous discectomy via radiofrequency ablation is without established clinical value. There is no Class I or long-term data to support the use of the proposed procedure for treatment of the patients low back pain. 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.