Complex Regional Pain Synd RSD denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intravenous ketamine infusions. Cohen and colleagues report, “Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded.” The authors further note that for CRPS, “There is moderate evidence supporting ketamine infusions to provide improvements in pain for up to 12 weeks,” and that, “In terms of duration of benefit, patient expectations and satisfaction should be considered, but based on the cumulative risks and costs of treatment, greater than three weeks following a single outpatient infusion and greater than six weeks following an inpatient or series of infusions are a reas…

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for a 28-day residential treatment center (RTC) program with the following CPT codes: 97112 x 96, 97116 x 96, 97530 x 96, 97535 x 96, 90837 x 15, 90846 x 4, 90847 x 4, 96151 x 12, 96154 x 12, 97810 x 8, and 97811 x 8. Findings: The physician reviewer found that a review of pediatric complex regional pain syndrome (CRPS), Weissmann and Uziel report, “Exercise and physical therapy (PT) are the main treatment cornerstones of all pediatric CRPS patients.” The authors further note regarding studies of pediatric patients with CRPS, “Brooke and Janselewitz reported complete resolution of pain in 25 of 32 children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home prog…

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a series of Ketamine infusions. The records reflect that this patient has a history of complex regional pain syndrome (CRPS) which has been refractory to medication management, acupuncture, chiropractic care, and interventional procedures. In a meta-analysis of the current medical literature regarding the effects of Ketamine infusion for treating CRPS, authors found that Ketamine treatment led to a decreased mean pain score in comparison to the self-controlled baseline. However, the authors further noted, “Our findings suggested that Ketamine infusion can provide clinically effective pain relief in short term for less than three months.

ature of Statutory Criteria/Case Summary: The patient is a 53-year-old female diagnosed with complex regional pain syndrome (CRPS) involving the left foot. Findings: The physician reviewer found that the patient underwent left gastrocnemius tendon recession, left foot subtalar arthrodesis, left first ray bunionectomy, left fifth toe hammer toe surgery, and left navicular resection with tendon interposition. A report dated 1/31/19 noted that the patient developed compartment syndrome a few days after the surgery and was treated in the emergency department and discharged. When her cast was removed, she developed severe post-operative pain, sensitivity to cold, touch, numbness, and inability to bear weight on the left foot that gradually worsened to the extent that she was unable to walk.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving complex regional pain synd rsd, then check the rights and deadlines that apply to your plan.