Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain.
Treatment: Pain Management Services / Spinal Cord Stimulator (2 units), Pre-service.

The insurer denied the Pain Management Services / Spinal Cord Stimulator (2 units), Pre-service.  The denial is overturned.

The patient is a male with history of intractable chronic low back pain due to lumbar spondylosis and herniated disc, affecting his activities of daily living (ADLs).

MRI (magnetic resonance imaging) lumbar spine showed L4-L5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) disc bulges, with L5 (fifth lumbar spine vertebra) nerve root impingement and L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) retrolisthesis.

The patient has failed conservative measures with medications, including Meloxicam, Diclofenac, Medial Dose Pak, and Gabapentin. He has also failed acupuncture, massage therapy, physical therapy and several spinal injections, including epidural steroid injections. The treating physician does not advise on any surgical decompression at the moment, because there is no clinical indication for it.

Yes, the requested health service is medically necessary.

The requested Spinal Cord Stimulator trial is medically necessary and should be covered by the health plan. The patient has exhausted all conservative measures. He has also met national standard criteria, including indication of chronic pain syndrome, chronic neuropathic pain secondary to lumbar radiculopathy, failed conservative measures as stated in clinical summary and also recommendation to proceed with the SCS (spinal cord stimulator) trial.

The Medical Necessity guidelines for Spinal Cord/Dorsal Column Stimulation Insertion, in line with general clinical practice as written under the Interqual Procedures criteria for Spinal Cord Stimulator insertion, and in line with national recommendations, state that spinal cord stimulators be reserved for patients who have failed conventional treatments and meet the following medical necessity criteria:

Electrical nerve stimulation:
Neuromodulation with electrical stimulus:  1) Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. In this instance, the patient has lumbar radiculopathy; 2) Spinal cord stimulation may also be considered for other selected patients (e.g., CRPS [complex regional pain syndrome], peripheral neuropathic pain, peripheral vascular disease, and post-herpetic neuralgia); 3) Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement; and 4) A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device. In this instance, the patient had 80% improvement with the trial.

In this instance, the patient has intractable chronic low back pain with radicular pain to both legs, and failed several conservative measures, as documented in the medical records review and stated above.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

As stated above, the requested Spinal Cord Stimulator is likely to be more beneficial than any other standard treatment for intractable chronic low back pain, as in this patient's case. It is therefore medically necessary, and withholding the procedure, in whole or in part is reasonably likely expected to affect the patient's health, as all other options for the treatment of the intractable chronic low back pain have been documented to have been exhausted. The patient has failed all conservative measures and has been ruled to be a good candidate for the Spinal Cord Stimulator.