Prolotherapy 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 prolotherapy. Nationally recognized evidence-based medical guidelines do not support prolotherapy for treatment of back pain. A systematic review and concluded that there is a lack of evidence demonstrating equivalent or superior efficacy for prolotherapy injections for chronic low back pain when compared to standard available therapies. The authors concluded that there is conflicting evidence regarding the efficacy of prolotherapy injections for patients with chronic low back pain. This patient presents with a history of progressively worsening low back pain radiating into her legs to her feet.

A 30-year-old female enrollee requested authorization and coverage of prolotherapy. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollee’s myofascial pain syndrome.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.

Where the denial was upheld

Physician 1The patient is a 54-year-old morbidly obese, type 2 diabetic who is suffering bilateral knee pain, low back pain, and neck pain. The patient has MRI confirmation of advanced degenerative joint disease. Ligaments and tendons of his left and right knees are grossly intact. Meniscal derangement is complex. Based upon the submitted records, the patient is independent with activities of daily living and driving. It has been recommended the patient undergo prolotherapy. The Health Plan has denied authorization for prolotherapy on the basis that it is considered experimental.The efficacy of prolotherapy for patients such as this patient has not been established. The ligament/tendon structure of the patient’s knees is grossly intact. In addition, the patient’s morbid obesity complicates any treatment approach for his knees including total replacement.

Physician 1: The patient is a 36-year-old female with cervical pain and swelling at the base of the neck. The etiology of her pain is not known. The patient reports that after two prolotherapy sessions she experienced improvement in her symptoms. She has requested authorization for six prolotherapy sessions, which the Health Plan has denied on the basis that the therapy is considered experimental.There are many different “protocols” of prolotherapy with no current obstructive data to define the dose, ingredients or frequency of injections to obtain tightening of ligaments. Additionally, the safety of prolotherapy is unknown. Furthermore, the patient has not exhausted standard therapies such as myofascial release, trigger point injections, electrical stimulation, etc.

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