Diagnosis: Orthopedic/Other/Spondylosis.
Treatment: Surgical Services/Radiofrequency joint denervation and/or ablation.
The health plan denied the requested Radiofrequency joint denervation and/or ablation as not medically necessary.
The health plan's determination is overturned.

The patient is a male with several years of chronic low back pain. Pain is axial in nature. No reports of radiculopathy. Physical exam is notable for tenderness to the paraspinals, sacroiliac (SI) joints and sciatic notches bilaterally. Painful lumbar range of motion. + facet challenge bilaterally. Neurovascularly is intact otherwise. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated degenerative changes without significant neural compression. An electromyography (EMG) /nerve conduction study (NCS) demonstrated no abnormalities. Prior treatments include previous injections, ((lumbar) L3/4 interlaminar with 80% pain relief x 2 months, bilateral radiofrequency ablation (RFA) L3 L4 L5 with 50-60% pain relief x 24 months, bilateral L3/4 L4/5 L5/S1 medical branch bock (MBB) and with 80% pain relief x 3 weeks), 4 weeks of physical therapy (PT) which made his symptoms worse, a home exercise program (HEP), chiropractor, Lyrica, narcotics, and muscle relaxers. The patient was once again recommended bilateral L3, L4, L5 RFA for the treatment of his pain.

The health plan's determinations of medical necessity are overturned, in whole, as per above.

Yes. The patient has facetogenic low back pain that is chronic in nature. It has been treated well with MBB and RFA in the past with most recent RFA lasting 2 years. That is significant pain relief for a low-risk procedure. It would be in the best interest of the patient to repeat the RFA and perform the requested treatment as ordered. To deny it would leave the patient in pain and be more costly to the health plan and health care system in the long run.
Health plan criteria for facet RFA is provided. The policy states facet RFA is medically necessary when ALL are met:
A. Findings an imaging identifies no other cause-> MET.
B. Pain x at least 3 months-> MET.
C. Patient has tried and failed conservative treatment for at least 4 weeks in the past 3 months-> MET.
D. 2 positive diagnostic facet injections/MBB with 80% pain relief-> MET.
The health plan criteria met. Therefore, no, the health plan did not act reasonably or with sound medical judgment nor in the best interest of the patient.