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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CPT-63185 and CPT-63190 for treatment of the enrollees annular tear of L4-L5 disc. Findings:  2/3 of the physician reviewers found that nationally recognized evidence based medical guidelines state that intradiscal electrothermal annuloplasty (IDET) is not recommended. The procedure is suggested for discogenic pain that is non-radicular and that has not responded to conservative treatment as an alternative to a fusion procedure. Colleagues conducted a systematic review. Based upon one high quality randomized controlled trial (RCT) showing efficacy and one moderate quality RCT interpreted as showing no benefit, they concluded that there is Level III, or moderate, evidence supporting the use of intradiscal electrothermal therapy (IDET) in treating chronic, refractory discogenic pain. Colleagues concluded a prospective, randomized, double blind, placebo controlled trial of intradiscal electrothermal therapy (IDET) for the treatment of chronic discogenic low back pain (CDLBP). They concluded that this study demonstrates no significant benefit from IDET over placebo. Colleagues conducted a randomized, placebo controlled, prospective trial of 69 of 1360 screened individuals who met the inclusion criteria of had discogenic low back pain lasting longer than six months, with no comorbidity, and positive clinical examination and discography findings. They concluded that the results of this trial cannot be generalized to patients who do not fit the strict inclusion criteria of this study. Nationally recognized evidence based medical guidelines state that facet joint rhizotomy is under study. Guidelines indicate that treatment requires a diagnosis of facet joint pain using a medial branch block with a required response of at least 70% pain relief. Inclusion criteria for medial branch blocks are limited to patients with non-radicular low back pain. Guidelines state that diagnostic facet blocks should not be performed in patients in whom a surgical procedure is anticipated.  The patient presents with a history of chronic lower back pain. The patient denies radicular pain but reports numbness in the fourth and fifth toes. Functional difficulty is reported in activities of daily living and recreational pursuits. There is electrodiagnostic evidence of bilateral L5 radiculopathy, and imaging evidence of a multilevel disc desiccation, including posterior annual tears without disc protrusion at the L4/5 and L5/S1 levels. Prior conservative treatment has included multiple epidural steroid injections and one facet injection, which reportedly were not beneficial. Evidence based medical guidelines and peer reviewed literature indicate that there is limited evidence to support the safety and effectiveness of the IDET procedure in patients with positive discogram over standard therapy. There is also a lack of evidence that this patient has a positive discogram. Evidence based medical guidelines and peer reviewed literature generally support the use of facet joint rhizotomy in patients with facetogenic pain confirmed by medial branch blocks with at least 70% pain relief. Additionally, the records do not show evidence that this patient has undergone a positive medial branch block to support the use of rhizotomy. Therefore, CPT-63185 and CPT-63190 are not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.