Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for coccygeal nerve ablation.Medical literature states that, Ablation is typically reserved for patients whose pain has failed to be adequately relieved via oral analgesic medications, cushions, coccyx steroid injections, and coccygeal sympathetic nerve blocks (ganglion impar). The ideal specific site for ablation may depend on the individual patients specific site of coccygeal pathology. Prior to ablation, a diagnostic injection (test injection, with local anesthetic) is generally performed to ascertain whether a specific target site is likely to provide relief if ablated. Patients who obtain substantial transient (anesthetic) relief via the diagnostic injection would be good candidates for subsequent nerve ablation at the same site where the diagnostic injection was done. Researchers concluded, Conservative treatment [of coccydynia] is successful in 90% of cases, and many cases resolve without medical treatment. Treatments for refractory cases include pelvic floor rehabilitation, manual manipulation and massage, transcutaneous electrical nerve stimulation, psychotherapy, steroid injections, nerve block, spinal cord stimulation, and surgical procedures. Moreover, researchers stated that pulsed radiofrequency (PRF) neuromodulation provides significantly longer pain relief and reduces the risk of recurrence of pain in chronic coccygodynia as compared with blockade of the impar ganglion.  A review by researcher revealed the following regarding nerve ablation for the coccyx: While the majority of the studies focusing on lumbar facet joints and sacroiliac joints suggest that radiofrequency ablation (RFA) significantly reduces pain in short-term follow-up, the evidence base for discogenic low back pain is mixed. There is no randomized controlled trial (RCT) evidence for RFA for the coccyx. Future studies should examine the clinical significance of the achieved pain reduction and the long-term efficacy of RFA.In this case, the patient has previously tried conservative treatment directed at pain in the coccyx. Prior treatment included medication, with limited relief, and injections, with mixed results. The medical records indicate that the patient has had mixed results with past three intercoccygeal disc injections. Additionally, the most recent injection provided three to four days of relief. A review of the medical literature reveals that there is a lack of controlled studies to support coccygeal nerve ablation in this clinical setting. Therefore, coccygeal nerve ablation is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine 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.