Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 17-year-old female who was involved in a motor vehicle accident in 2003, sustaining a musculoligamentous strain involving the cervical and lumbosacral spine causing residual cervicogenic headaches, lumbosacral pain, and comorbid depression. She has been treated by a physiatrist and a neurologist. It has been suggested that the patient be treated with an RS-4i sequential stimulator. The Health Plan has denied coverage for the requested equipment on the basis it is considered investigational.There is no class I literature supporting the use of the RS-4i sequential stimulator for treatment of patients such as this patient. This is considered an experimental treatment and is not the standard of care. Furthermore, there are available therapies with established efficacy for treatment of this patients condition. Because of the lack of evidence supporting the efficacy of the requested RS-4i sequential stimulator, and the availability of other appropriate therapies, I have determined 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 2: The patient is a 17-year-old female who is requesting an RS-4i interferential stimulation unit to assist with controlling her pain from fibromyalgia and possible cervical facet syndrome. The Health Plan has denied this request indicating the efficacy of the requested equipment for treatment of the patients diagnoses has not been established.The Health Plans denial should be upheld. An interferential stimulator is generally considered experimental for treatment of pain conditions including fibromyalgia. There are no published, peer-reviewed controlled trials demonstrating the efficacy of interferential stimulators for chronic pain due to fibromyalgia. In general, exercise, low dose NSAIDs, and anti-depressants are considered the foundation of treatment for the patients condition. 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 3: The patient is a 17-year-old female who is requesting authorization for an RS-4i interferential stimulation unit. She was injured in a motor vehicle accident in 2003. She is being treated with several pain medications along with an antidepressant, all which have not proven beneficial for her chronic pain. She is requesting authorization for an RS-4i interferential stimulation unit, which the Health Plan has denied.The efficacy of the RS-4i interferential stimulator for treatment of fibromyalgia has not been established. In addition, the submitted medical records show that the patient tried using a RS stimulator jacket (which uses the RS-I unit) and this aggravated her condition. For these reasons, it is unlikely the requested equipment will result in a superior outcome to standard treatment modalities. 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.