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

Physician 1: The patient is a 22-year-old woman with a history of juvenile lumbar disc disease. She had undergone conservative treatments with no long-term benefit. The patients provider has recommended the patient undergo an IDET procedure, which was performed in November 2003. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. As such, use of IDET for treatment of patients such as this patient is without clinical merit. Therefore, I have determined that the procedure at issue was 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 22-year-old female who had significant low back pain secondary to changes in her lower lumbar discs consistent with juvenile lumbar disc disease. Given the patients age, lumbar fusion was not recommended. In November 2003, the patient underwent an intradiscal electrothermal therapy (IDET) procedure, which reportedly has been very effective. The Health Plan indicates there is insufficient scientific evidence demonstrating the long-term safety and efficacy of IDET. Therefore, the Health Plan considers the procedure experimental and has denied reimbursement.For this patient, IDET is expected to produce a significant improvement over standard treatment such as fusion. The efficacy of IDET has been to reduce a patients pain compared to placebo in a randomized placebo-controlled trial. The submitted clinical information indicates the patient has tried and failed conservative modalities and was not an appropriate candidate for fusion in light of her age. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 22-year-old female with a history of low back pain due to disc disease. She had failed conservative care. It was recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The patient has been pain free following the procedure. The Health Plan indicates has denied reimbursement for the IDET procedure indicating the long-term efficacy of the procedure has not been established.There is sufficient class I data in peer-reviewed journals demonstrating the efficacy and safety of IDET at two-year follow-up in patients with discogenic low back pain refractory to extensive conservative care. Given the patients age and remaining disc height, IDET was likely to be more effective than standard treatment (i.e., fusion). The submitted information indicates the patient has in fact experienced pain relief since the IDET procedure and continues to be pain free almost two years following the procedure. Accordingly, I have determined the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.