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

Physician 1The patient is a 64-year-old man with compression fracture of T9, T12, and L1-3. It has been recommended that the patient proceed with vertebroplasty and/or kyphoplasty because of the failure of conservative treatment. The Health Plan has denied authorization and coverage for the requested procedures indicating that vertebroplasty and kyphoplasty are considered investigational in nature.The patient has attempted conservative measures including rest, medication, and physical therapy, yet he has persistent pain. The submitted medical records demonstrate that the patient is a candidate for vertebroplasty and kyphoplasty. Vertebroplasty and kyphoplasty have a proven place in the treatment of compression fractures.  The procedure devices have been approved by the Food and Drug Administration and numerous reports have shown the efficacy of the procedures. Since conservative treatment has failed, the patient is likely to receive greater benefit from vertebroplasty and kyphoplasty than from standard therapy.Based upon the information set forth above, I have determined that the requested procedures are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2The patient is a 64-year-old man who has compression fractures of the spine that have not responded to conservative measures. The patient has utilized pain medications, antispasmodic medications, physical therapy, bracing, and bed rest without relief. The patients provider has recommended a vertebroplasty and kyphoplasty. The Health Plan indicates the efficacy of the requested procedures has not been demonstrated.The patient has multiple vertebral compression fractures that have been recalcitrant to conservative measures. Vertebroplasty and kyphoplasty have been shown to be very effective for immediate and lasting pain relief. Vertebroplasty has been used for over 10 years with excellent results. The submitted records indicate the patient has exhausted conservative treatment. Therefore, I have determined that the requested procedures are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 64-year-old man with multiple levels of osteoporotic vertebral compression fractures. The patient has been treated with conservative measures including pain mediations, antispasmodic medications, physical therapy, bracing, and bed rest. The patient wishes to undergo vertebroplasty and kyphoplasty. The Health Plan has denied the patients request on the basis that the requested procedures are considered experimental.The clinical efficacy of vertebroplasty and kyphoplasty has not been clearly established. It is unclear whether these procedures will provide significant benefit to the patient. Given that the long-term efficacy of vertebroplasty and kyphoplasty has not been established these procedures cannot be recommended. Therefore, I have determined that the requested procedures are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.