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

Physician 1: The patient is a 58-year-old male with chronic myofascial pain syndrome who is seeking authorization and coverage for ongoing pain management through multiple therapies. The Health Plan has denied coverage for the requested procedures on the basis they are considered experimental. The Health Plans denial should be upheld. This patient has chronic myofascial pain syndrome. Percutaneous lysis of epidural adhesions has not been proven to be effective for treatment of patients such as this patient. Furthermore, facet nerve injections and spinal injection for myelography are not indicated in this patient who does not have a clear focal pain generator delineated by diagnostic methodology. 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.Physician 2: The patient is a 58-year-old man who has osteoarthritis of the knees, degenerative disc disease, sacroiliac pain, myofascial pain, and chronic arthritis. He underwent a fusion in 1997 without success. The patient is requesting coverage for percutaneous lysis of epidural adhesions, facet nerve injections, and spinal injection for myelography. The Health Plan has denied his request indicating the requested procedures are experimental.Recent systemic reviews for percutaneous lysis of epidural adhesions, facet nerve injections, and spinal injection for myelography have supported their use. The treatment plan proposed by the patients pain management program has sufficient evidence of efficacy that it is superior to alternative treatment or no treatment. Based upon the information provided, it appears the patient is an appropriate candidate for the requested procedures. 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 3: The patient is a 58-year-old male who has a history of degenerative disc disease and chronic myofascial pain. He is post surgical fusion in 1997. The patient has requested authorization for percutaneous lysis of epidural adhesions, facet nerve injections, and spinal injections by myelography. The Health Plan has denied the patients request indicating the requested procedures are considered experimental.This case involves a request for several injections. First, percutaneous lysis of epidural adhesions is considered investigational and not of proven efficacy. To date, there has been only one controlled study of small size. As such, there is insufficient data to support lysis of epidural adhesions in this case.In addition, request has been made for coverage for spinal injections for myelography. Review of the submitted documentation does not demonstrate spinal injections for myelography were mentioned in the patients treatment plan. Since the purpose/goal or diagnostic result to be achieved has not been delineated there is no apparent value in this procedure.Furthermore, the patient is seeking authorization for single level facet nerve injections. Documentation from 11/15/04 does report the patient had facet pain. In addition, the MRI dated 11/22/04 documented hypertrophy of facets at L3-4 and L5-S1. Therefore, use of facet injections is medically reasonable and appropriate and likely to be more effective than standard therapy.Based upon the information set forth above, I have determined that although facet nerve injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, lysis of epidural adhesions and spinal injections for myelography are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.