Piriformis Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Myobloc (Botox) injections for treatment of the enrollee who has a history of fibromyalgia, irritable bowel syndrome, piriformis syndrome, and ankylosing spondylitis. Findings: The physician reviewer found that The documentation provided notes that the requested treatment option was to address the patient’s piriformis syndrome, a variant of myofascial pain syndrome. A small study by Fishman and colleagues compared Botox injections with corticosteroid and lidocaine injections for the treatment of piriformis syndrome and found a greater decrease in pain with Botox injections. An open label comparator study by Yoon and colleagues noted that Botox appeared superior to dexamethasone with lidocaine by the visual analogue scale.

Findings: The physician reviewer found that a patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lower back and pelvis. According to the American College of Radiology appropriateness criteria for the evaluation of low back pain, in a patient with history of prior lumbar surgery, with radiculopathy and new symptoms, MRI is considered usually appropriate for further evaluation. MRI can accurately distinguish recurrent disc herniation versus scarring from prior surgery. It can also evaluate for nerve root compression. In this case, the enrollee has new radicular symptoms in the setting of prior lumbar surgery, and updated imaging is needed to guide further management. Thus, the requested MRI of the lower back is indicated for this patient. Additionally, MRI of the pelvis is critical in the diagnosis of piriformis syndrome and nerve entrapment.

Where the denial was upheld

Physician 1The patient is an 18-year-old female who has sciatic pain as a result of a fall. A request has been made for sciatic entrapment release and placement of anti-scarring agent. The Health Plan has denied authorization for the requested procedure on the basis that it is considered investigational.Although treatment of piriformis syndrome is somewhat difficult using standard techniques, the requested procedure is without established efficacy. There is no scientific evidence demonstrating the requested procedure is likely to be of any benefit in this case. In the absence of proven beneficial effects there is no indication for the requested procedure. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested complex open magnetic resonance (MR) guided piriformis resection, neuroplasty of the superior gluteal nerve, neuroplasty inferior gluteal nerve as well as neuroplasty of the sciatic nerve in the ischial tunnel, including decompression neuroplasty of the posterior femoral cutaneous nerve and inferior cluneal branches for treatment of her medical condition. Findings: Two physician reviewers found that this patient has chronic gluteal/pelvic pain. However, before any surgery is recommended, all other sources of pain must be ruled out. The submitted records do not document that this has been done in this case, since there is no documentation of hip imaging or urologic or gynecologic examinations/imaging. Piriformis syndrome and surgery is considered controversial.

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