Myofascial Pain Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 44-year-old woman who has been experiencing left thoracic pain resulting from a motor vehicle accident that occurred some time ago. In spite of a long list of medications and procedures the patient has continued to experience pain in a left thoracic distribution. She has undergone nerve block and trigger point injections leading to temporary relief. The examinations by several physicians suggest that the origin of the patient’s pain is due to a disease, such as a ruptured or protruding thoracic disc. The patient indicates that Botox injections have been beneficial. She has requested authorization for further Botox therapy. The Health Plan has denied the patient’s request indicating the efficacy of Botox has not been established.It appears the patient’s pain is due to a combination of postural changes and muscle spasms.

Physician 1: The patient is a 58-year-old male with chronic myofascial pain syndrome who is seeking authorization and coverage for ongoing pain management through multiple therapies. The Health Plan has denied coverage for the requested procedures on the basis they are considered experimental. The Health Plan’s denial should be upheld. This patient has chronic myofascial pain syndrome. Percutaneous lysis of epidural adhesions has not been proven to be effective for treatment of patients such as this patient. Furthermore, facet nerve injections and spinal injection for myelography are not indicated in this patient who does not have a clear focal pain generator delineated by diagnostic methodology. Therefore, I have determined that the requested procedures are not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Where the denial was upheld

Physician 1: The patient is a 46-year-old female with myofascial pain syndrome. The pain has been present for several years, affecting the left lower rhomboid mid-thoracic region. She has consulted a number of physicians. She has been seen and examined by a neurologist who made valuable suggestions for the treatment of her long-standing pain syndrome. The submitted evidence reflects the fact that the patient has been treated with a number of medications, including: Ultram, cyclobenzaprine, Flexeril, Elavil, Vioxx and Vicodin. She also has had the benefit of trigger point injections. None of these measures have provided the desired relief. X-rays and an MRI scan have revealed mild degenerative changes at T7-8, but no major abnormalities. The patient wishes to try Botox injections for treatment of her myofascial pain syndrome.

Physician 1: The patient is a 42-year-old male who experienced an injury while fighting a fire resulting in shoulder/periscapular pain that has persisted over 1.5 years. He has attempted conventional therapeutics including physical therapy, oral medications, home exercises and trigger injections without relief. Imaging of the spine showed no clinically relevant abnormalities. EMG showed no radiculopathy or plexopathy. A request has been made for authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox is considered investigational in this clinical setting.The patient has a myofascial pain syndrome status post trauma and surgery. The medical literature regarding Botox and pain relief is substantial when looking at dystonia as the underlying diagnosis.

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