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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services from a pain management specialist (60-74 minute office/outpatient visit for a new patient - high MDM, 80 minute office consultation for a new patient; 40-54 minute office/outpatient visits for an established patient - high MDM; drug tests presumptive capable of being read by direct optical observation; and drug tests presumptive, read by instrumented assisted direct optical observation) and/or radiofrequency ablation (RFA) services. Per the Department of Health and Human Services (HHS), The development of a treatment plan should be preceded by a history and physical examination that aids in proper diagnosis. When clinically indicated, clinicians should consider an integrative and collaborative approach to care. Specialty interdisciplinary pain medicine team consultation, collaborative care, and (when indicated) mental health and addiction services should be readily available in the course of treatment of pain to help ensure the best patient outcomes. Per Tompkins and colleagues, current pain management treatment options include opioid and non-opioid pharmacotherapies, physical therapy, psychological and behavioral therapies, complementary and alternative medicine strategies, peripheral procedures, spinal procedures, and surgery. This patients records document conservative treatment in attempts to manage ongoing back pain. The patient has been treated with RFA with 25% relief and epidural steroid injections with 40-50% relief for three to five days. The records also document that the patient has a history of opioid agreement violations including failed urine drug screens and overdose requiring hospitalization. The patients provider noted that the patient is not considered an ideal candidate for treatment with opioids. On review of the available documentation, the requested services from a pain management specialist, drug tests, and RFA services are not indicated for this patient. The patients notes demonstrate only minimal pain reduction and no functional improvement from previous RFA procedures. Additionally, previous epidural injections provided only a few days of improvement. Given the failed conservative treatment, contraindication to opioids, and poor outcome from previous interventional procedures, it is unclear what additional pain management consultation would be expected to add to this patients care. All told, the requested services from a pain management specialist (60-74 minute office/outpatient visit for a new patient - high MDM; 80 minute office consultation for a new patient; 40-54 minute office/outpatient visits for an established patient - high MDM; drug tests presumptive capable of being read by direct optical observation; and drug tests presumptive, read by instrumented assisted direct optical observation) and RFA services are not medically necessary for treatment of this patient.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 subspecialty 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.