Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1:  The patient is a 54-year-old male who has chronic back pain with disc degeneration and chronic multiple compression fractures due to a motor vehicle accident in May 2003. He is requesting authorization and coverage for a kyphoplasty. The Health Plan has denied this request citing the procedures lack of proven efficacy in this setting.Kyphoplasty is not likely to be effective in cases of multiple chronic compression fractures and multiple-level degenerative disc disease. Additionally, the patients injury occurred in 2003; a kyphoplasty performed three years from the time of injury is not likely to be beneficial. The procedure is considered experimental in this setting involving multiple chronic fractures and severe disc degeneration. Review of the scientific data reveals the refracture rate is high and the long-term outcomes are unknown.Based upon the information set forth above, 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. Therefore, the Health Plans denial should be upheld.Physician 2:  The patient is a 54-year-old male who injured his back in a motor vehicle accident in May 2003. He sustained compression fractures of T8 and T10. He has had persistent pain (in spite of appropriate conservative treatment), which is only alleviated by using pain medications in excess of prescribed dosages. His orthopedic surgeon recommended a kyphoplasty. The Health Plan has denied authorization for the proposed procedure on the basis that it is considered experimental and investigational.Review of the submitted clinical evidence indicates the patient has exhausted attempts at standard therapies. Kyphoplasty is a minimally invasive procedure without significant risk. There are no contraindications to the procedure based on the information provided. Given the absence of additional treatment modalities, a kyphoplasty is medically reasonable in this circumstance. For these reasons, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 3:  The patient is a 54-year-old man with chronic back pain secondary to injuries he sustained in a motor vehicle accident in 2003. He has evidence of thoracic compression fractures. A request has been made for kyphoplasty. The Health Plan has determined kyphoplasty is considered investigational and therefore is not a covered benefit.Kyphoplasty is no longer an experimental/investigational procedure and is routinely performed along with vertebroplasty for treatment of compression fractures. It is FDA approved and guidelines have been established for its use. In this case, however, the fractures are chronic. The patient was involved in a motor vehicle accident in 2003. Kyphoplasty and vertebroplasty are best performed during the acute phase. The patients fractures have long healed. There would be little benefit in performing the procedure at this time. As such, it cannot be recommended. In conclusion, 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.