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

Physician 1:  The patient is a 48-year-old female with anterolisthesis at L5 and S1 and spondylosis at L5 confirmed by MRI.  She has undergone medial branch nerve block on the right, and it has been recommended that she undergo radiofrequency thermocoagulation of the medial branch nerves on the left.  The Health Plan considers the procedure experimental and has therefore denied the patients request for authorization.The proposed procedure is experimental at this time.  There is no class I data to support the use of radiofrequency coagulation/ablation for the treatment of lumbar spondylosic back pain. The long-term outcomes for this procedure are unknown and the literature does not support its use in patients such as this one. As the efficacy of radiofrequency coagulation/ablation has not been clearly established, I have determined that the requested procedure is 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.Physician 2:  The patient is a 48-year-old female with a history of several lumbar surgeries and chronic back pain. A March 2006 MRI showed anterolisthesis of L5 on S1 and spondylosis at L5. The patient was treated with lumbar medial branch nerve blocks on the right and is now requesting authorization for radiofrequency thermocoagulation of the left lumbar medial branch nerves. The Health Plan considers this procedure experimental and has denied authorization and coverage.Lumbar medial branch nerve blocks have some diagnostic utility in identifying the source of pain and may predict the response to other interventions. In general there is a high rate of false positive responses with this procedure; two to three diagnostic blocks should be performed to confirm the joint is symptomatic. The utility of medial branch blocks as either a diagnostic or therapeutic modality in the post-operative spine however, remains investigational. There is no compelling proof that the medial branch block is efficacious in the diagnosis or treatment of chronic back pain for patients who have undergone previous surgery. Therefore, I have determined that the requested procedure is 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.Physician 3:  This patient is a 48-year-old female who is status post lumbar laminectomy and fusion that has debilitating low back pain. She underwent right lumbar medial branch nerve blocks with positive results. Her provider has requested authorization for radiofrequency thermocoagulation of the left lumbar medial branch nerves. The Health Plan denied the request citing the investigational nature of the procedure in this clinical context.Several placebo-controlled studies have been conducted on radiofrequency ablation/coagulation.  For some pain specialist, this procedure is the standard of care for facet pain diagnosed by dual discogenic medial branch nerve blocks. However, in this case the requisite confirmatory diagnostic medial branch nerves blocks have not been performed on the left. Under these circumstances, I agree that the requested procedure is 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.