Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Low Back Pain (LBP). 
Treatment: Spinal Neurostimulator, service. 

The insurer denied coverage for spinal neurostimulator, service. 

The denial is upheld. 

The patient has a medical diagnosis of chronic low back pain (LBP). The treating provider is requesting plan approval for treatment with spinal cord neurostimulator (SCS). 

The patient has the past medical history (PMH) with the medical diagnosis of chronic low back pain (LBP). The patient's lumbar spine magnetic resonance imaging (MRI) scan revealed posterior lumbar (L)4 to L5 postoperative changes and mild disc bulging. Neuropsychological evaluation revealed no psychosocial factors that predict poor response to installation of a spinal cord stimulator. The patient reported low back pain with bilateral lower extremity radiation. The patient's past medical history includes diabetes mellitus (DM). A history of unspecified lumbar spine surgery was noted. The pertinent medications include Lyrica and oxycodone. On physical examination (exam) of the lumbar flexion of spine and extension were mildly restricted. The patient's straight leg raise (SLR) was positive bilaterally. Prior treatment included epidural steroid injections and medial branch blocks. An undated appeal letter discussed literature regarding spinal cord stimulators. The treating provider ordered spinal cord neurostimulator (SCS), which is the topic of this review. The treating provider prescribed therapy with spinal cord neurostimulator (SCS) service. 

"Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column A fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non-standard, stimulation waveforms such as high-frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy." (Sdrulla, et al.,). 

A discussion of failed back surgery syndrome (FBSS) Baber and Erdek conclude "After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modification and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations." 
                                                      
The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for a spinal neurostimulator is upheld. Medical Necessity is not substantiated.