Complex Regional Pain Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for all or any residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 3.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Nalu Neurostimulation System. There are a number of treatment modalities available to treat challenging chronic pain syndromes. First line strategies generally involve pharmacotherapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, antiepileptics, and antipsychotic or antidepressant agents, followed by invasive procedures including injections with longer acting anesthetics and corticosteroids, depending on the location or anatomic target. When these techniques yield results, ablative procedures, which carry the risk of a permanent neurological deficit or deafferentation syndromes, may be pursued. If persistent structural problems, surgical intervention may be appropriate.

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.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right carpal tunnel syndrome and complex regional pain syndrome (CRPS). The provider noted that the patient underwent a right carpal tunnel release that was complicated by a postoperative infection requiring an incision and drainage procedure. The provider noted the patient had findings consistent with CRPS, including hyperhidrosis of the right-hand fingers, shiny skin, and nerve pain with proximal radiation. The patient was previously treated with a stellate ganglion block, which reportedly was not beneficial. The patient has also been treated with Lyrica and Valium. The patient was noted to be allergic to Pamelor, and she did not want to try another nerve pain medication. The provider noted a second surgery to release scar tissue could be beneficial.

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 syndrome, then check the rights and deadlines that apply to your plan.