Failed Back Surgery Syndrome: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for methadone tablets with a quantity of 180 tablets every 30 days for chronic pain. Concerning this issue of whether clinicians should continue with opioid therapy for chronic pain, the Centers for Disease Control and Prevention (CDC) indicate that providers should carefully weigh the benefits and risks and exercise care when changing the opioid dosage. If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a replacement battery for her spinal neuro-stimulator and a pain pump to regulate morphine dose for treatment of her post lumbar spine surgery syndrome and lower extremity compartment syndrome. Findings: The physician reviewer found that the spinal cord stimulator is clinically supported for treatment of the patient’s medical condition. The patient indicated that the device has provided pain relief but that currently the battery needs replacement. A randomized controlled study by Deer and colleagues supports the efficacy of spinal cord stimulation (SCS) in treating failed back surgery syndrome and complex regional pain syndrome. Taylor and colleagues note that spinal cord stimulation was effective in reducing pain irrespective of the location of the chronic pain.

Where the denial was upheld

A 36-year-old male enrollee has requested rhizotomy for treatment of his back pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the procedure at issue. According to Chan and Peng, failed back surgery syndrome is a challenging clinical entity with significant impact on the individual and to better prevent and manage this condition, knowledge of the factors contributing to its development is necessary. In regards to postsurgical spine syndrome, Ordia and Vaisman indicates that the degenerated disc collapses causing misalignment of the facet joint which could result in facet pain. The authors note that diagnostic facet medial branch injections may help to determine who may benefit from radiofrequency rhizotomy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Senza High Frequency spinal cord stimulator for treatment of his medical condition. Findings: Three physician reviewers found that there is a lack of support for the requested device in this clinical setting. High frequency spinal cord stimulation is a new approach to providing analgesia in failed back surgery syndrome. This modality is currently undergoing a clinical trial in various chronic pain states. Although some research presents promising data, the studies to date are small and have been funded by the company. In sum, the current medical evidence has not established the superior efficacy of the requested device. Final Result: Three reviewers determined that the requested device is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for failed back surgery syndrome was denied, the published record says the denial is worth fighting.