Prior authorization of non-opioid pain care prolongs patient suffering

A patient on long-term opioid therapy for the treatment of back pain was successfully tapered off all opioids after Illinois anesthesiologist David Walega, MD, implanted a temporary spinal cord stimulator (SCS) during a 10-day trial period. Objectively she was able to increase her quality time with her young children and husband, she was able to sleep restfully and uninterrupted by pain for the first time in five years, and told Dr. Walega that she was so happy “to finally get her life back.” Prior to the SCS trial, she had lost her job due to the severity of pain and side effects from opioids, was mostly bed-ridden and deeply depressed.

Upon completion of the SCS trial, Dr. Walega submitted the required forms and letters of medical necessity to obtain prior authorization and approval to implant a permanent SCS system. The health insurer’s specialty benefit management company, however, denied the SCS on the basis that the device and treatment was not “medically efficacious.”

After months of appeals to the specialty benefit management company, which was located in California, and the physician reviewer, who was located in Florida, Dr. Walega was finally able to obtain approval to implant a permanent SCS for this patient. Yet, the appeals process—including the initial denial, follow-up denial and then peer-to-peer review by the health insurance company physician—took hours that Dr. Walega said cut into the time he was able to spend with patients.

“She went through eight months of additional pain, depression and anxiety when we had a proven treatment that was clearly helping her,” said Dr. Walega. “But since the permanent implant, she’s back to being a mom, goes on walks with her husband, and is working toward getting back in the job market. She is not using any opioids at all.”

For Dr. Walega’s other patients who would benefit from SCS, he reports that denials are increasingly common, and it is rare that the physician reviewer for the health plan is an anesthesiologist or pain specialist. In fact, a recent peer-to-peer review for a patient with neuropathic arm pain from myelomalacia was performed by a pediatrician.

“I have the deepest respect for my physician colleagues, but these health plans are using physicians to deny care when that physician has never practiced pain medicine, never trained as an anesthesiologist nor used SCS or other interventional therapies,” Dr. Walega explained. “It’s ludicrous and maddening.”

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