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

Physician 1:  The patient is a 47-year-old male who reportedly has peripheral neuropathy in the feet, with described loss of sensation and burning sensation. A report from his neurologist does not detail any abnormalities of sensation, strength or reflexes. No information is evident regarding confirmation of neuropathy by electrodiagnostic examination, or regarding diagnostic evaluation for etiology. The patient has reportedly tried Cymbalta, though the dose is not specified. He did not have benefit from it, though no side effects were specified. He reportedly has been on Neurontin but the dose and degree or lack of benefit is not indicated. No other medications for treatment of neuropathy are mentioned in the records provided.The patient was prescribed Anodyne therapy; treatment notes indicate he had short-term improvement. The patient has requested a home unit to treat himself with Anodyne therapy.The patient probably has polyneuropathy based on his symptoms, though neurologic examination as documented does not specifically support the diagnosis. There is no submitted or available scientific data supporting the value of this treatment for polyneuropathy. The efficacy of Anodyne therapy has not been established through well designed studies. There is no evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities. Furthermore, the cause of the patients neuropathy does not appear to have been thoroughly investigated. Treating the underlying cause may lead to marked improvement of neuropathic pain. Although therapy with Neurontin was reportedly ineffective for this patient, the dose is not specified and it may be that the prescribed dosage was inadequate. Standard neuropathy medications such as tricyclics or pregabalin should also be considered. Therefore, I have determined that the requested equipment 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:  This patient is a 47-year-old male with chronic peripheral neuropathic pain. He is requesting authorization and coverage for an Anodyne infrared phototherapy unit for pain management. The Health Plan has denied his request citing a lack of proven efficacy.Anodyne infrared phototherapy has not been critically analyzed nor are there randomized, controlled trials in the peer-reviewed literature demonstrating its safety and efficacy in long-term use for chronic peripheral neuropathic pain. At this time, Anodyne infrared therapy is not a generally accepted medical modality in peripheral neuropathic pain management. Given the lack of proven efficacy associated with Anodyne therapy, I have determined that the requested equipment 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 47-year-old man with a diagnosis of neuropathy with pain and imbalance. The etiology, physical findings, and previous management are not included in the records provided. The patient remains on Neurontin and was previously treated with capsaicin cream and Cymbalta. He reports significant relief of pain and improved balance with Anodyne therapy and requests coverage for a home unit. The Health Plan has denied his request.The literature does not support the use of Anodyne therapy. The only placebo-controlled double blinded study available showed no difference between Anodyne therapy and placebo. Anodyne therapy is not a standard or accepted therapy for neuropathy in the neurologic literature or in practice. There is no evidence the patient has tried Lyrica or tricyclic antidepressants, which are more likely to be helpful than Anodyne therapy. Therefore, I have determined that the requested equipment 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.