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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the radiofrequency denervation for treatment of the enrollees chronic severe left intercostal chest wall ribs pain and left thoracic costovertebral junction syndrome status post left thoracotomy.  Findings:  The physician reviewer found that In the documentation available for review, the provider does not document a pain diary for the intercostal block done prior to the radiofrequency ablation. The literature is clear how a diagnostic blocks are supposed to be done prior to radiofrequency ablation with use of a pain diary for the day to verify when the local anesthetic wore off, using only local anesthetic, and not using sedation (Derby, et al; Falco, et al). In this case, the blocks lasted longer than the duration of the local anesthetic, steroids and sedation were also used. Furthermore, there is no discussion regarding the specific types of conservative care for intercostal neuralgia. There are different types of medications being used to successfully treat neuropathic pain and intercostal neuralgia after thoracotomy (Mendlik and Uritsky). In addition, no physical examination was performed to confirm the diagnosis at the treated levels, and the procedure performed exceeds the number of levels done on the prior nerve block. Finally, there is limited evidence in the form of a few case studies and one small randomized control trial to support the procedure as safe and effective in this clinical setting (Engel). Therefore, the radiofrequency denervation provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in anesthesiology 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.Physician reviewer number two is board certified in anesthesiology 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.Physician reviewer number three is board certified in anesthesiology 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.