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

Physician 1The patient is a 34-year-old female with cervical myofascial pain and muscle spasm. She has requested coverage for use of an RS-4i Sequential Stimulator for relief and management of her chronic pain and acute condition. The Health Plan has denied this request indicating the requested equipment is considered experimental for treatment of the patients medical condition.Review of the clinical information provided reveals the patient has a post-traumatic myofascial pain syndrome and comorbid depression. Diagnostic testing established the diagnosis of chronic myofascial pain. She was prescribed a large number of medications, many of which were not helpful.  She also attempted trigger point injections and other physiotherapeutic modalities, which did not provide adequate and lasting relief. The RS-4i Sequential Stimulator provided the patient with the desired relief of pain. Sequential stimulators can provide beneficial effects in difficult pain situations and does appear to be successful in treating this patients chronic pain. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. The patient should continue to use the RS-4i Sequential Stimulator for six months at which time she should be reevaluated.Physician 2The patient is a 34-year-old female with cervical myofascial pain and muscle spasm. Her provider indicates the patient has not responded to standard therapies. The patient has used an RS-4i Sequential Stimulator in the past with reported benefit. She has requested coverage for continued use of an RS-4i Sequential Stimulator. The Health Plan has determined the requested equipment is considered investigational for treatment of cervical myofascial pain.Interferential stimulation therapy has not shown to be of proven efficacy for chronic pain control in the case-controlled, peer-reviewed literature. Furthermore, the medical literature fails to demonstrate that interferential stimulation is of superior efficacy as compared to conventional TENs unit treatment. As such, the patient is likely to receive greater benefit from conservative therapies than from use of an RS-4i Sequential Stimulator. Therefore, I have determined that the requested equipment 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 3The patient is a 34-year-old female with chronic cervical myofascial pain who has requested coverage for use of an RS-4i Sequential Stimulator. The patient has been involved in several injuries and is status post shoulder arthroscopy on 3/25/04. She continues to have myofascial pain involving her shoulder, which has only temporarily been relieved by trigger point injections and cervical traction. The patient was placed on use of an RS-4i Sequential Stimulator but it is unclear from the documentation provided how effective the equipment has been in the treatment of the patients myofascial pain.Current medical literature does not support the use of interferential stimulation therapy for treatment of chronic myofascial pain. In fact, the results of placebo-controlled trials have reported negative findings of interferential stimulation therapy. There is no data demonstrating that treatment with an RS-4i Sequential Stimulator is more efficacious than other standard therapies such as the use of a TENS unit. Therefore, I have determined that the requested equipment 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.