Diagnosis: Neck/back pain.
Treatment: Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level.

The insurer denied Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level. The health plan's determination is upheld.

This is a female patient diagnosed with lumbar radiculopathy, Vertebrogenic Pain, Intractable Chronic Migraine without Aura and without Status Migrainosus, Cervical Spinal Stenosis, Degenerative Disc Disease (Lumbar). Records show that requests for Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product was denied by the health plan as experimental and investigational. The provider notes that the patient has chronic back pain and has tried multiple conservative treatments including nonsteroidal anti-inflammatory drugs, analgesics, opioids, physical therapy, home exercise program, and epidural steroid injections.

The Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Low back: Not recommended for low back conditions including fusion or low back pain. An systematic review (SR) / MA (meta-analysis) of platelet-rich plasma (PRP) efficacy for chronic low back pain identified 6 studies (196 patients) of intradiscal injection for disk degeneration, 5 studies (670 patients) of epidural injection, 3 studies (151 patients) of lumbar facet joint injection, and 3 studies (54 patients) of sacroiliac joint injection; all but one study was observational. Trending of improved pain scores were noted at 12-month follow-up in the MA of the epidural and lumbar disc injection groups, while MA could not be performed in the other categories. However, findings were limited by heterogeneity, small sample size, and lack of clinically meaningful results." While it appears the patient has had chronic back pain that has not significantly responded to prior conservative management and epidural steroid injections, there are alternative treatments as well as traditional surgical measures that can be utilized.

There is no evidence to suggest this treatment is superior to that of standard means of treatment for this condition and it would not be considered medically necessary or standard of care as a remains experimental and investigational. Further studies are needed to establish long-term safety and efficacy of this procedure.