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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis for treatment of the enrollees recurrent back pain. Findings:  Two physician reviewers found that the patient was status post L4/5 microdiscectomy. The treating providers report indicated that the patient received one week of pain relief following the caudal and left L5 transforaminal epidural steroid injections. She reported that she also had pain on the right and left lumbar areas with burning and shooting pain down her legs. She felt like her back and legs were going to give out. A lumbar spine examination documented normal alignment and no tenderness to palpation. Range of motion was documented as flexion 90 degrees, extension 15 degrees, and negative straight leg raise at 70 degrees. Lower extremity neurologic examination was reported within normal limits. The diagnosis included post laminectomy syndrome, degenerative disc disease lumbar spine, and low back pain. She had only short term relief with epidural injections. She reported that she was not ready for back surgery but had significant pain and was unable to work at this time. The treatment plan recommended bilateral L4/5 facet/medial branch blocks as a pain control measure. The operative report documented that bilateral L4/5 intraarticular facet joint steroid injections with medial branch blocks were performed. The providers report indicated that the patient reported an acute flare-up of her back pain after returning to work. She reported sharp pains in the central lumbar area and that her back had locked up the last two nights. Pain was radiating slightly up the spine and made it nearly impossible to move. She was taking tramadol and gabapentin without benefit. Lumbar spine examination documented normal alignment and no tenderness to palpation. The patient is requesting coverage for radiofrequency neurolysis. The Health Plan denied the requested services as investigational for treatment of this patients medical condition. Evidence based medical guidelines and peer reviewed literature do not support the use of radiofrequency neurotomy in the treatment of disc herniation or in the absence of a positive response to facet injections for six weeks and greater than 70% pain relief with subsequent medial branch blocks. Peer reviewed literature generally supports radiofrequency ablation for treatment of lumbar spondylosis when the diagnosis is made by medial branch block. This patient presents with persistent radicular low back pain, increased after return to work. She was status post prior L4/5 microdiscectomy. Imaging demonstrates a recurrent focal disc protrusion indenting the thecal sac with spinal canal stenosis and neural foraminal narrowing with bilateral L4 nerve root compromise. Prior epidural steroid injections have provided short term pain relief. The documentation provided does not corroborate a diagnosis of facet mediated pain. Facet intraarticular injections and medial branch blocks were performed without documentation of response. One study found no high-quality evidence suggesting that radiofrequency (RF) denervation provides pain relief for patients with chronic lower back pain. Similarly, they identified no convincing evidence to show that this treatment improves function. Overall, the evidence for RF neurolysis for chronic low back pain is very low to moderate in quality. High-quality studies with larger patient samples are needed, as are data on long-term effects. Therefore, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts 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.