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

Physician #1:  The patient is a 27-year-old male with a long history of back pain, which has increased over time. There is no history of significant trauma. There are extensive medical records describing evaluation and treatment over the past three years. Symptoms have persisted and the patient has been using narcotics for pain control for some time. He has a dorsal kyphosis and percutaneous kyphoplasty at T7 and T8 has been proposed. The Health Plan has denied coverage for the kyphoplasty on the basis that it is investigational in nature.The patients complaints and findings are consistent with Scheuermann's disease of the vertebral bodies, which reduces the mechanical integrity of the bone as is the case with osteoporosis, metastases, etc. As such, the proposed procedure is not an appropriate option for this patient who has otherwise healthy bone. Kyphoplasty is not medically indicated in cases such as this and is not likely to result in an improved clinical outcome. 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 #2:  The patient is a 27-year-old male with a history of thoracic pain for the past three years. He is requesting authorization for percutaneous thoracic kyphoplasty. The Health Plan has denied authorization for the requested procedure on the basis that the benefits of percutaneous kyphoplasty have not been scientifically established.  Although percutaneuous kyphoplastay is a medically appropriate and indicated procedure for certain patients, the clinical indications for the procedure are not met in this case. This patient, with a three-year-history of mid-back pain and MRI and CT scans without evidence of acute fracture, is not a candidate for kyphoplasty. None of the radiographic studies show that the patient has a wedge compression fracture that is acute and causing pain. Rather, he has chronic pain without evidence of significant compression, and as such, is not an appropriate candidate for the procedure. The kyphoplasty is not indicated and would not be beneficial in treating the patients condition.Based upon the information set forth above, 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 #3:  The patient is a 27-year-old male with thoracic pain for the past three years. He has attempted multiple conservative treatment modalities without sustained relief. He is requesting authorization for percutaneous thoracic kyphoplasty. The Health Plan has denied this request.Kyphoplasty is not likely to be successful in cases of thoracic back pain lasting for three years. Vertebral augmentation procedures are effective for acute compression fractures, but there is no literature to suggest that they are effective in cases of long-term thoracic back pain. Given the duration of the patients pain, kyphoplasty is not a viable option and cannot be recommended. 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.