Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a 58-year-old female who is status post cervical surgery. She continues with upper back pain, muscle spasms, and generalized weakness of the upper back, neck and arms. The submitted notes indicate the patient has undergone therapy with an RS4I sequential stimulator with some improvement. Her physician has recommended continued use of the RS4I sequential stimulator. The Health Plan has denied this request indicating the requested equipment is considered experimental for treatment of the patients condition. The Health Plans denial should be upheld. There is insufficient evidence the requested equipment is efficacious for treatment of the patients symptoms. There are no long-term studies to warrant its use. Nor is there evidence demonstrating the requested equipment is more efficacious than a TENS unit or other similar devices. The alternative treatment suggested by the Health Plan is medically reasonable and appropriate. 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 2: The patient is a 58-year-old female with chronic pain and weakness status post cervical spine surgery. Her condition has been refractory to conservative treatments. The patient has requested authorization for an RS4I sequential stimulator for pain management. The Health Plan has denied the request on the basis that the requested equipment is considered experimental. Current medical literature does not support the use of interferential stimulation therapy for treatment of the patients condition. The RS4I stimulator has not been proven to be efficacious in randomized, controlled clinical trials published in peer-reviewed literature. There is no data demonstrating that treatment with an RS4I 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. Physician 3: The patient is a 58-year-old female with chronic pain status post cervical spine surgery. Her condition has been refractory to conservative treatments including physical therapy, a TENS unit, and anti-inflammatory and pain medications. The patient has requested coverage for an RS4I sequential stimulator for pain management. The Health Plan has denied the request on the basis that the requested equipment is considered experimental. Review of the submitted evidence demonstrates the patient maximized her medical treatment without change prior to receiving sequential stimulation therapy. A sequential stimulator can provide beneficial effects in difficult pain situations and does appear to be successful in treating this patients chronic pain. Based upon the patients failure of standard therapies and her response to a previous trial of sequential stimulation therapy, I have determined the requested equipment 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.