Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1:  The patient is a 75-year-old male with a history of low back pain following a motor vehicle accident in 1963. He had lumbar fusions in 1970 and 1987. The patient had significant pain, minimally responsive to narcotic pain medications. There is an operative report indicating that in January 2006 he had caudal epidural steroid injection with lysis of epidural adhesions using RACZ catheter under fluoroscopic guidance. The Plan denied the patients request for reimbursement citing the experimental/investigational nature of the lysis of epidural adhesions procedure.The procedure that was performed in January 2006 included two components. One aspect of the treatment was an epidural steroid injection and the other was lysis of epidural adhesions using RACZ catheter. Epidural steroid injections are a commonly used therapy for low back pain, with established efficacy. The lysis of adhesions which was done using a RACZ catheter, on the other hand, is not a commonly accepted or widely used technique.   There is no support for the assumption that this aspect of the procedure was likely to provide a greater benefit to the patient than would the epidural steroid injection alone.  Therefore, I have determined that the procedure at issue was 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 75-year-old male with lower back pain following a motor vehicle accident, of more than 40 years duration.  His pain is rated as 7/10 and radiates to his lower extremities.  He underwent lysis of adhesions with an epidural steroid injection in January 2006 to treat his condition and has requested reimbursement for the procedure. The Health Plan denied his request based upon a determination that the procedure was experimental/investigational in this clinical setting.There is no Class I data to support the efficacy of lysis of adhesions for the treatment of chronic lower back pain. This treatment approach is not the standard of care within the orthopedic community and is not likely to be effective in the long term.  This procedure remains experimental/investigational for the treatment of the patients medical condition and has not been shown to provide clinical benefits beyond those available with standard therapies.  The Health Plans denial should be upheld.Physician 3:  The patient is a 75-year-old male with chronic lower back pain following spinal fusion at multiple levels.  He had unrelenting pain that was interfering with normal daily activities such as walking and standing. Treatment with Norco and Duragesic patches was ineffective and he was referred for epidural steroid injections and lysis of epidural adhesions. The health plan has classified this treatment approach as experimental/ investigational and denied his request for reimbursement.Lysis of epidural adhesions (epidural neurolysis) also known as the RACZ procedure is performed following an epidurogram to determine the presence or absence of epidural adhesions.  The RACZ catheter is inserted into the epidural space and an injection of hypertonic saline with or without steroids or other medications is used.  In theory, the hypertonic saline solution causes a mechanical disruption of the epidural adhesions. The adhesions may also be disrupted by the manipulation of the catheter at the time of the injection to further the penetration of the drugs into the scar tissue. The injection may be performed with or without endoscopic guidance.  The benefits of the procedure are as yet unproven and lysis of epidural adhesions, or epidural neurolysis, remains an investigational/experimental procedure without clearly established clinical efficacy. As such, I have determined that the procedure at issue was 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.