Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic pain. 
Treatment: Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.

The insurer denied coverage for Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation.  The denial is upheld. 

This is a male patient with chronic lower extremity pain of uncertain etiology.  He was seen by a Pain Management Specialist.  The patient's treatment has been extensive.  He is status post laminectomy with T11-12 syringomyelia for resection and biopsy for an intradural arachnoid cyst.  His current symptoms are reportedly "worsening neuropathic pain around his knees bilaterally, greater on the right side that is also associated with numbness, tingling, dysesthesia and allodynia from mid-thigh down to right below his knees."  However, he remains physically active.  The pain reportedly increases with activity.  

Radiological studies (X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans of thoracic and lumbar spine) did not demonstrate evidence of correlating pathology.  Knee MRI scan also did not demonstrate evidence of specific pathology.  Electromyography (EMG) was normal.  Various treatments included epidural steroid injection, T10-12 laminectomy and resection of subarachnoid cyst with lysis of adhesions, which were of no particular benefit.  There has also been a recommendation for placement of a syringo-ostomy at T11-12.  Other treatments include physical therapy and various medications.  Genicular nerve blocks reportedly provided some relief for only 24-48 hours "at most".   A second block reportedly provided longer duration of relief.   Currently under review is the medical necessity for the pre-service request for electrical stimulation for the treatment of pain and muscle rehabilitation.

The patient's Pain Management Specialist has proposed a variety of treatments including right genicular nerve blocks, radiofrequency denervation, epidural steroid injection, sympathetic nerve blocks, spinal cord stimulator, acupuncture, and various medications including Amitriptyline, Cymbalta, Lyrica, Meloxicam and Voltaren gel.  From a physical medicine and rehabilitation/pain management perspective, as well as within reasonable degree of medical certainty, based on the lack any correlated pathology via imaging and EMG studies, lack of specific diagnosis and lack of  sustain relief from multiple treatment interventions, the requested peripheral nerve stimulation (PNS) is also unlikely to provide any sustained pain relief.  An extensive clinical work-up has failed to demonstrate evidence of specific pathology that correlate with the patient's reported bilateral lower extremity "neuropathic pain.  Treatment has been extensive (surgeries, various injections, physical therapy and multiple medications) without sustained pain relief.  The requested PNS is likely to result in similar ineffectiveness.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, as well within a reasonable degree of medical certainty, the pre-service request for electrical stimulation for the treatment of pain and muscle rehabilitation is not medically necessary.

The carrier's denial of coverage for the Pre-Service Request for Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation is upheld.  The medical necessity is not substantiated.