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

Physician 1:  The patient is a 24-year-old male who sought and received decompression therapy with the DRX 9000 system. He had a chronic lower back condition that had been unresponsive to medications and physical therapy and a broad-based disc bulge on MRI.  Prior to the decompression therapy, the patient described his pain as 6 on a 0 to 10 scale. Approximately 19 treatments were provided with an indication that his condition was stable as of March 2006.  The Health Plan has denied the patients request for reimbursement based upon their determination that the therapy at issue was experimental/investigational for treatment of his back pain.At this time, a review of current literature fails to provide sufficient supporting evidence that the DRX 9000 decompression system provides a superior clinical benefit over conventional treatment modalities. The patient is likely to have experienced similar results with standard therapies or standard forms of traction. Therefore, I have determined that the therapy at issue was 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 24-year-old male with lower back pain due to central disc protrusion at L5-S1. He experienced moderate back pain with some radiation to the left thigh.  Conservative treatment had not been effective and he discussed the DRX 9000 system with his primary care provider and requested a referral. The therapy is considered experimental/investigational by the Health Plan and the patients request for reimbursement was denied.    Multiple studies on traction have not demonstrated a greater efficacy in relieving symptoms due to disc bulge/herniation. Furthermore, there are no randomized, controlled studies showing the superiority of the DRX 9000 system when compared to standard treatment modalities for the management of lower back pain. At this point in time, the use of the DRX 9000 system remains investigational in the treatment of discogenic pain.  Based upon the information set forth above, I have determined that the therapy at issue was 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:  This patient is a 24-year-old male with a history of chronic low back pain due to a disc bulge at L5-S1.  He failed earlier conservative treatments, and apparently did not want to pursue epidural steroid injections.  The patient asked for a referral for lumbar traction and began treatment with the in DRX 9000 system in February 2006. He is now requesting reimbursement for the therapy. The Health Plan denied his request indicating the DRX 9000 system was experimental/investigational for the treatment of his disc-related pain.The Health Plans denial should be upheld. The DRX 9000 system is an unproven modality in the treatment of lower back pain caused by a bulging disc. There are no peer-reviewed, controlled trials demonstrating its efficacy in the treatment of this type of pain. Furthermore, the use of the DRX 9000 system is not consistent with the standard of care for the treatment of disc disease within the medical community. Therefore, I have determined that the therapy at issue was 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.