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

Physician 1: The patient is a 51-year-old woman with low back pain. She underwent paraspinal surface electromyography (EMG) on multiple occasions. The patient reports that surface EMG is required at regular intervals to prevent flare-ups of her low back pain, which can lead to several days of incapacitation. The Health Plan has denied coverage for the surface EMG procedures indicating that the safety and efficacy of this technique has not been established.Paraspinal surface electromyography (EMG) is investigational and is not of proven efficacy for diagnosing or guiding treatment of back pain. The patient indicates that surface EMG is required to prevent flare-ups of her back condition. However, surface EMG is not a treatment modality and therefore has no effect on flare-ups of this kind. Furthermore, there is no evidence surface EMG is a more effective diagnostic tool than standard percutaneous electromyography. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for evaluation and 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 with a history of low back pain. Paraspinal surface electromyography (EMG) procedures have been utilized by the patients provider as part of her care. The patient indicates that when she stopped receiving these treatments her back pain returned, sometimes lasting five to seven days. The Health Plan has denied coverage for the paraspinal surface EMG procedures on the basis the procedures are experimental and investigational in nature.Upon review of the relevant medical literature, paraspinal surface EMG findings do not correlate conclusively with severity of low back pain. There is no evidence that utilization of surface EMG results in improved clinical outcomes beyond standardized examinations and treatments. The use of standard diagnostic procedures would have been more efficacious in this case. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for evaluation and 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 woman with a history of low back pain. She has undergone paraspinal surface electromyography (EMG) and has requested reimbursement from her Health Plan for the procedures. The Health Plan has denied the patients request indicating that paraspinal surface EMG is experimental.Paraspinal surface EMG remains experimental at this time. There are no long-term prospective studies to warrant its use in the evaluation and treatment of patients such as this patient. Risks, complications, benefits, and outcomes are not known. The procedures at issue are not considered standard of care; there is no indication that surface EMG provides any benefit other than placebo. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.