Diagnosis: Low back pain
Treatment: Spinal Cord Stimulator, two units
The insurer denied the spinal cord stimulator, two units.
The denial was upheld.
The use of dorsal root ganglia is not considered medically necessary for this patient.
The patient is a female with history of post laminectomy syndrome. The patient has attempted physical therapy (PT), medications, radiofrequency ablation (RF) ablation, acupuncture, and massage without improvement. She had previous L5-S1 decompression.
The patient underwent dorsal root ganglion (DRG) trial which provided significant relief. The patient was recommended for DRG nerve stimulator for treatment of pain related to anterior superior iliac spine (ASIS) musculature.
The patient's pain is noted to be mainly in the low back and does not correlate with the ASIS muscles that were described. The notes do not support that DRG stimulation would be beneficial based upon the clinical documentation provided and it is not well documented the outcomes from the previous DRG trial. Notes do indicate the patient was considered for lumbar fusion as well as spinal cord stimulator trial. Based upon all the documentation provided, the proposed DRG stimulator is not medically necessary.
The denial is appropriate and there is insufficient evidence provided that the patient would benefit from DRG stimulation; therefore, it is not deemed medically necessary for this patient.