Diagnoses:

Pain in the thoracic spine; Lumbago; Closed fracture of dorsal (thoracic) vertebra

Summary:

The client had been referred for a surgical procedure in an attempt to better manage the pain thought to be a result of multiple compression fractures in his spine. The physician had been continuing the patient on narcotic pain medications in increasing doses and suggested he may have more pain control with a spinal cord stimulator. This procedure would involve two steps, a trial stimulator period and then, if effective, an additional surgery for a more permanent placement of the spinal cord stimulator.

Cost Savings:

The MRC Nurse Consultant evaluated the medical necessity of the spinal cord stimulator trial procedure by reviewing the clinical documentation. Additional information was obtained telephonically from the physician's office and the client to ensure that all information was available and considered. Multiple neurosurgical best practices criteria and medical policies were researched to cross-reference appropriateness for determination of medical necessity. Based on all the documentation reviewed and the criteria established, the MRC Nurse Consultant appropriately determined that the procedure recommended in this case was not indicated for the client's diagnosis; it was considered experimental/investigational and therefore not a covered benefit. The client was very appreciative and understanding of the determination and will work with his treating team of physicians to consider alternatives to the surgery proposed. The physician's office did indicate that they would explore alternative treatments for the client.

As a result of obtaining additional information and researching the procedure, the MRC Nurse Consultant was able to determine that this procedure was considered experimental/ investigational for this client in this situation. Without MRC's intervention, the ineffective surgical treatment would have been completed and paid as a covered benefit.

Hospital charges and ongoing maintenance charges avoided: $ 98,094

Total Cost Savings: $ 98,094