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Insurance company benefits managers.

April 14, 2013

A few weeks ago my husband was scheduled for facet injections following a severe flare of his chronic low back pain.  The facets are PE-Facet_Figure2small joints on the back of each vertebra where the vertebrae touch each other.  Pain in the facet joints is a result of arthritic changes as we age.  The hallmark of facet pain is pain with leaning backward or arching the spine.  It can be difficult to definitively diagnose where the pain is coming from as other conditions such as degenerative disc disease or spinal stenosis can cause similar pain.  Facet injections are a diagnostic procedure in which anesthetic and steroid are injected into the joint space.  If the pain is relieved, even if only for a short time, you know the facet is a source of pain.  If not, then suspicions falls on these other diagnoses.  See NYU Langone Medical Center’s page for a more detailed explanation.  The illustration on the left comes from Mayfield Clinic’s website.

My husband’s doctor had determined by history and thorough physical exam that the most troublesome part of his pain appeared to be facet related.  Thus scheduling facet injections to confirm and get on the road to giving him more relief than he is currently getting on long acting morphine tablets.  Unfortunately, the insurance company denied approval for the procedure.  This caused us to get yet another MRI of my husband’s spine to prove what the doctor already knew.

So why was this procedure denied, then later approved after two more doctor visits and a $2000 MRI?  No one involved in my husband’s care had any question that he has facet pathology, including the neurosurgeon who actually looked at his facets while performing a 3 level laminectomy to remove a fatty mass from the epidural space two years ago.  The easiest answer is the insurance company was being cheap and hoped he would go away.  I’m sure Humana doesn’t see it that way, at least publicly.

Actually, Humana removes themselves from this process by hiring a company called OrthoNet: Integrators of Orthopaedic Care to review orthopedic claims.  OrthoNet reviews claims and looks for reasons the insurance companies should not pay for the care ordered by the doctor.  The way they word it sounds nicer:

Our innovative care management model integrates the needs of providers, payors, and members to ensure the delivery of high quality, cost-effective care while realizing substantial savings that keep the costs of healthcare down.

Essentially they are paid not just to say no, but to rationalize the denial in such a way that it is difficult for patients to appeal the denial.  Otherwise, why would an insurance company spend the money to outsource claim review?  The cost of hiring OrthoNet plus the claims paid would have to cost less than Humana reviewing the claims themselves.  They expect OrthoNet’s decisions to cost them less.

Here is an excerpt from the letter my husband received explaining denial of his procedure:

The records strongly suggest that you experience chronic pain that is related to radiculopathy.  These symptoms, however, appear to be responding to traditional medical management (75% pain relief with medicines).  Besides, your treatment history does not suggest that facet injections were safer and more effective for managing these symptoms.  Hence, we determined the request does not meet criteria. Therefore it is not approved for prior authorization.  We have also notified your provider of this decision.

OrthoNet is under contract with Humana to provide coverage of health care services as authorized and provided under the terms of the Humana Medicare Programs product.  We used Medicare guidelines for this decision.

Let me explain what is meant by radiculopathy.  This is dysfunction of a nerve caused by compression or interruption of blood supply where the nerve root exits the spine.  One common cause of

Herniated intervertebral disc compressing a lumbar nerve root.

Herniated intervertebral disc compressing a lumbar nerve root.

radiculopathy is herniated intervertebral discs.  For a comprehensive discussion of disc herniation diagnosis and treatment, see this article on the American Academy of Orthopaedic Surgeons’ website.  One of the key

Straight leg raise test.

Straight leg raise test.

indicators of disc related radiculopathy is pain with the straight leg raise.  A negative straight leg raise test (absence of pain down the leg and below the knee) indicates a low likelihood of lumbar disc herniation.

So, despite negative straight leg raise and positive indicators of facet pain, previous documentation of facet pathology both by MRI and by direct visualization by a surgeon, and the treating doctor’s diagnosis of probable facet pain syndrome, a “medical director” at OrthoNet is diagnosing probably radiculopathy pain.  Also, would anyone consider 75% relief of constant, excruciating pain enough?  I know I wouldn’t.

Ultimately, my husband got the extra testing and got his injections.  He had dramatic relief of the constant lower back pain he has had for several years for a few days.  This is considered a positive diagnosis of pain originating in the facet joints injected.  The PE-Facet_Figure3next step, if pain relief is short lived as in this case, is facet rhizotomy.  This is a procedure in which the nerve fibers transmitting pain signals from the facet joint are destroyed using radio-frequency energy through a small probe.  For a more detailed description of this procedure see the Mayfield Clinic site.  (For the record, I have no knowledge of Mayfield Clinic other than their website.  I have referenced their pages due to the high quality of their illustrations and explanations.)

So, all’s well that ends well, right?  For now, yes.  But taking just a brief look around the net, I see OrthoNet has quite a long reach.  They have (or have had) contracts with many large insurance companies besides Humana such as Aetna, Cigna, and Blue Cross Blue Shield.  This may save the insurer money, but I suspect in the long run it costs patients and Medicare more due to reduced function and quality of life, more diagnostic imaging and other tests to prove what the treating doctor already knows or strongly suspects based on actually seeing and talking to the patient and knowing their history.  I sure would prefer my doctor to make these decisions than some bean counter doctor that barely glanced at my records.  I doubt those doctors get bonuses for correctly approving procedures.

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