Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe left neural foraminal stenosis

Treatment: Spinal Cord Stimulator

The insurer denied coverage for Spinal Cord Stimulator. The denial is reversed.

This patient is a female with a history of being struck by a motor vehicle. At that time, the patient's computed tomography (CT) scan of her spine showed severe left neural foraminal stenosis at L5-S1 with compression of the left nerve root at L5 secondary to disc bulging and bilateral facet hypertrophy.  The patient's lumbar magnetic resonance imaging (MRI) showed mild degenerative changes.  The patient had a right pubic symphysis fracture. The patient underwent rehabilitation treatment for a short period of time and then resumed with inpatient rehabilitation. The patient had also attempted multiple medications to control her pain.  Neurology noted that the patient's pain was in the low back and bilateral legs (right leg greater than the left leg to the feet) with numbness and tingling in the right leg.  The patient underwent a psychological evaluation for the spinal cord stimulator, and the patient was considered to be a good candidate for this device.  The patient's pain levels were 7 to 10 out of 10 in severity that affected both her physical and mental health, as well as incurred functional limitations.  The patient continued to have low back pain that radiated into the lower legs to below the knees at times.

The American Association of Neurological Surgeons state, "Spinal cord stimulation (SCS) is a relatively new technology that can help manage chronic pain when the cause cannot be removed or the injury cannot be repairedAfter a patient has been evaluated and non-surgical treatments have been used, spinal cord stimulation is considered to help manage chronic pain.  A patient will often undergo mental health testing and counseling so they understand how an implanted device will be managed" According to the Centers for Medicare and Medicaid Services (CMS), Medicare has a National Coverage Determination (NCD) for Electrical Nerve Stimulators (NCD 160.7) that addresses Spinal Cord (Dorsal Cord) Stimulation.  The following conditions must be met for Medicare to make payment for this service: The implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic, intractable pain; Other treatment modalities (pharmacological, surgical, physical, or psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or contraindicated for the given patient.

Based on the review of the medical record, the spinal cord stimulator trial would be medically necessary.  If the patient receives at least 50% benefit, a permanent placement of a spinal cord stimulator would be medically necessary. In this case, the patient had trialed the use of a transcutaneous electrical nerve stimulation (TENS) unit and showed immediate relief of pain. The patient's treating physician determined that based on this patient's response to the TENS unit, a spinal cord stimulator should be able to effectively relief her pain.

The patient was not a good candidate for surgical intervention as per her evaluating neurosurgeon. However, the literature review supports that the spinal cord stimulation would be a safe and effective treatment option that could be easily reversed if needed, to treat this patient's medical condition. Thus, the spinal cord stimulator is considered medically necessary to treat this patient's severe, intractable back pain.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Spinal Cord Stimulator should be reversed.  The medical necessity is substantiated.