Elect Bone Stim denials: what the review data shows

Where the denial was overturned

Physician 1: The patient is a 64-year-old woman who sustained a clavicle fracture in May 2004. At the time the patient was evaluated by an orthopedist union was not yet established and osteopenia was noted. A bone growth stimulator was recommended. The Health Plan indicates a bone growth stimulator is considered investigational for treatment of patients such as this patient. Bone growth stimulators are of proven efficacy and have been used with great success over the past twenty years. As the patient’s provider indicates, the only other treatment option for this patient who was at eight weeks from date of injury with no obvious callus formation or union, would have been surgery, plating and bone grafting of the fracture. Use of a bone growth stimulator was medically appropriate and necessary to attempt union of the patient’s fracture.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for RT300 SLSA functional electrical stimulator (FES). In this case, the patient has a diagnosis of locked-in state. Emphasizing the need for significant multidisciplinary rehabilitation, Researchers report that multimodal treatments that are frequent and sensory can provide significant improvement for patients with locked-in syndrome. The authors further note that FES has been found to be particularly beneficial. Researchers explain that locked-in syndrome is a rare condition that results in tetraplegia and that although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described. Because locked-in syndrome is so rare, there is a lack of high quality studies that examine the efficacy of various treatments.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an ultrasonic bone stimulator. Fowler and Hughes state, “Scaphoid fractures are the most common carpal bone fracture, usually occurring in young men, although the incidence in women has increased over the past decade. Snuffbox tenderness and/or pain with axial loading of the thumb should be treated as a scaphoid fracture until proved otherwise and the diagnosis confirmed with serial radiographs and/or advanced imaging. Nearly all displaced scaphoid fractures should undergo operative intervention to reduce the risk of nonunion. Nondisplaced fractures have high union rates with cast treatment, but require extended periods of immobilization.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Functional Neuromuscular Electrical Stimulating Ergometer (The RT300 FES Therapy System).Findings: Two out of three physician reviewers found that the requested Functional Neuromuscular Electrical Stimulating Ergometer (The RT300 FES Therapy System) is not likely to be more beneficial than any other available standard therapy for the patient’s condition.In a systematic review and meta-analysis, Eraifej and colleagues evaluated the effectiveness of post-stroke upper limb functional electrical stimulation (FES) on activities of daily living (ADL) and motor outcomes. A systematic review of randomised controlled trials (RCTs) was carried out.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Elect Bone Stimwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.