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

Physician 1The patient is a 44-year-old woman with long-standing back pain. She has chronic pain that has been treated with medication, therapy, injections, and facet blocks. The patient has requested authorization for radiofrequency ablation of her lower back lesions. The Health Plan has denied the request indicating that the requested procedure is considered investigational.Although further study is warranted, there are certain circumstances where radiofrequency ablation is warranted. It is used under specific circumstances to alleviate chronic pain. Since the patient in this case did achieve pain relief with facet blocks she is an appropriate candidate for radiofrequency ablation.  The patient is likely to receive longer lasting relief from radiofrequency ablation than from continued conservative therapy. Therefore, I have determined the requested procedure is 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 2The patient is a 44-year-old female with back pain and radiculopathy. The patient has received relief from lumbar transforaminal epidural injections and medial branch block. She has requested authorization and coverage for radiofrequency ablation. The Health Plan has denied the patients request on the basis that radiofrequency ablation is considered investigational for treatment of back pain.The requested procedure is investigational and lacks established long-term clinical efficacy. There is insufficient evidence that facet ablation with radiofrequency provides more than temporary relief. The requested procedure is not likely to be efficacious for treatment of the patients back pain and will not improve her radiculopathy. 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 3The patient is a 44-year-old female with chronic low back pain since March 2003, which is apparently related to facet syndrome. An MRI performed in July 2003 revealed degenerative facet joints. The patient has not achieved significant pain relief from lumbar facet injections; however, lumbar transforaminal epidural injections and medical branch block have provided significant pain relief. The patient has requested authorization for radiofrequency ablation, which has been denied by the Health Plan on the basis that it is investigational.Although radiofrequency ablation is not currently the standard of care for treatment of low back pain, it has been performed for treatment of patients such as this patient. Facet injections, which are frequently administered in treatment of chronic low back pain caused by facet syndrome, provided minimal relief in this case. Facet blocks, which are performed not only for pain relief but also as a diagnostic test prior to more permanent procedures, have been effective for this patient. As such, the patient is an appropriate candidate for radiofrequency ablation. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.