Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic regional pain syndrome 
Treatment:  IVIG
The insurer denied the IVIG.  The denial is upheld.

The patient is a female.  A treatment note indicates that the patient was receiving ongoing treatment of IVIG (intravenous immunoglobulin) and had three treatments and tolerated them well for her complex regional pain syndrome.  The pain syndrome reportedly persisted.  She was described with some vesicular-like eruption involving both lower extremities with the pain being relatively well controlled.

A follow-up note indicated that the patient continues to get care.  The patient is getting immunoglobulin treatments.  She continues to get ketamine infusions.  Last week was more in the way of left knee pain and lower leg pain.  She developed some skin changes in the left foot very similar to what she developed on the right foot in the past consistent with complex regional pain syndrome.  She was having less pain over the last day or two with no specific trigger.  She was recommended to do home exercises and continued care, per the treating provider.

A note indicated that the patient described severe neck pain, left jaw pain, shooting pain.  It was described that she had left leg darker than the right and she was going to be stopped on opioids and start titrating the low-dose naltrexone.  A note indicated treating provider noting pain of knee region with complex regional pain syndrome, low back pain.  The patient is being treated with ketamine.  She had a knee injection with Euflexxa.

The available medical records provided for review reflect a request for intravenous immunoglobulin for the treatment of complex regional pain syndrome.  The available medical records provided for review described a submission of an article, plasma exchange therapy in patients with complex regional pain syndrome, Pain Physician, is noted in review of this article that almost all the patients who were tested with skin biopsy were concurrently diagnosed with small-fiber neuropathy or had other immune related disease.  The available medical records provided for review do not reflect that the patient has been diagnosed with small-fiber neuropathy or other immune-related disease.  The available medical records provided for review described the patient as being diagnosed with complex pain regional syndrome.  Treatment notes reflect ongoing use of intravenous immunoglobulin but also noted persistent pain.  As such, the available medical records provided for review are unclear if the patient is improving with the IVIG that has been administered to date.  Given that the available medical records provided for review do not reflect an immune-related condition that has been demonstrated to be responsive to IVIG, the available medical records provided for review do not support the medical necessity for treatment with intravenous immunoglobulin.  As such, the proposed treatment is not medically necessary based on the medical records provided for review.

The available medical records again provided for review do not reflect the patient has been diagnosed with an autoimmune or other immunologic condition demonstrated to have effective treatment by intravenous immunoglobulin.  The available medical records provided for review do not reflect the patient as having skin biopsy or having been diagnosed with small-fiber neuropathy.