Idet denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 42-year-old female with chronic discogenic low back pain secondary to internal disc derangement at L4-5 and L5-6. The patient underwent provocation discography on 8/17/04 demonstrating diffuse annular disruption at L4-5 and midline radial fissure at L5-6. The patient’s provider has recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan indicates the requested procedure is considered experimental and has not been established as more effective than available standard therapies.Review of the submitted clinical information indicates the patient is not a candidate for microdisectomy, fusion or chemonucleoplasty. In addition, the patient has not had significant relief from other treatments utilized such as medications, epidural injections, and facet joint block injections.

Physician 1: The patient is a 22-year-old woman with a history of juvenile lumbar disc disease. She had undergone conservative treatments with no long-term benefit. The patient’s provider has recommended the patient undergo an IDET procedure, which was performed in November 2003. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. As such, use of IDET for treatment of patients such as this patient is without clinical merit.

Where the denial was upheld

Physician 1: The patient is a 41-year-old woman with chronic back pain. A request has been made for an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied this request on the basis that IDET remains experimental/investigational.There is no information available to warrant and support the use of IDET in the treatment of this patient. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. In this community, when IDET has been used the results have been poor. As such, IDET cannot be recommended until the efficacy of the procedure has been established. 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.

Physician 1: The patient is a 42-year-old male who sustained an injury to his back six months ago and has since been on restricted work duty since. He has degenerative disc disease and is requesting coverage for an intradiscal electrothermal therapy (IDET) procedure for his disc herniation.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. At this time, there is no class I data to support the use of IDET for the treatment of lumbar degenerative disc disease. In fact, the recent article by Freeman, et al. in Spine 2005 utilizes class I data to refute the effectiveness of the procedure. IDET cannot be recommended until the efficacy of the procedure has been established.

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