Issued and entered November 20, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 16, 2002, Petitioner XXXXXXXXX, filed a request for an external review with the Commissioner of Financial and Insurance Services (Commissioner) under MCL 550.1901 et seq., the Patient’s Right to Independent Review Act. The Commissioner’s staff assessed the material submitted by the Petitioner and accepted the request.

A determination on medical issues was required. The Commissioner assigned the case to Permedion, an independent review organization (IRO). The Commissioner directed Permedion to obtain the opinion and recommendation of a medical expert.

The IRO completed its review on November 7, 2002, and sent it to the Office of Financial and Insurance Services (OFIS). A copy of the report is attached.

II
FACTUAL BACKGROUND

Petitioner has a history of chronic lower back pain. In June of 2000, he experienced severe lower back pain, radiating to his left medial inguinal area. He sought care in the past from his family practitioner and a chiropractor. His physician prescribed non-steroid anti-inflammatory medications.

In August 2000, he sought treatment from Dr. XXXXXXX. Dr. XXXXXXX recommended active physical therapy consisting of a lumbar rehabilitation program. The program began on September 26, 2000, ended on January 25, 2001, and it focused on physical therapy treatments on the “MedX” lumbar and cervical extension machines at the XXXXXXXXXXXXXXXXXX.

Aetna Life Insurance Company (Aetna) denied coverage for the physical therapy treatments alleging they were considered “investigational” for treatment of Petitioner’s condition.

III
ISSUE

Whether Aetna complied with the terms of its Certificate of Insurance when it denied coverage for physical therapy treatments using the MedX lumbar and cervical extension machines, claiming they were experimental or investigational and not covered under the policy?

IV
ANALYSIS

Petitioner’s Argument

The Petitioner's application for external review did not contain any specific arguments or issues of dispute. The case file contained only the Respondent's materials and its adverse determinations. The adverse determinations denied coverage alleging the physical therapy treatments using the MedX lumbar and cervical extension machines were "experimental or investigational" relating to the Petitioner's medical condition. Since the Petitioner did not provide any information, the Commissioner must presume he simply disputes the Aetna's allegation.

Aetna Life Insurance Company’s Argument

Aetna issued its revised final adverse determination on July 2, 2002. It reviewed the documentation and concluded the use of the MedX lumbar and cervical extension machines to be experimental or investigational in the treatment of Petitioner’s back injury.

Aetna stated in its final adverse determination letter:

A charge for a service or supply is not covered to the extent that it is determined by Aetna U.S. Healthcare to be experimental or investigational.

Aetna U.S. Healthcare does not cover the use of MedX lumbar/cervical extension machine. Although there is limited evidence that when used as a training device, the MedX system can help to increase the strength of the lumbar as well as the cervical extensors, it has not been proven that the MedX machines are more effective than standard exercise equipment in functional strengthening or contribute more to patient management than other currently available equipment and technology. Therefore, the Plan will not cover this service.

Independent Review Organization (IRO) Recommendation

The expert physician who reviewed this case is in practice and board certified in Physical Medicine and Rehabilitation. The expert reviewed all documents and arguments presented and concluded the MedX lumbar/cervical extension machines remain an investigational type of equipment. The expert stated the MedX machine has not been proven (via peer-reviewed literature) to be more effective than standard exercise equipment in functional strengthening. The expert recommends that Aetna’s denial of coverage for physical therapy using the MedX lumbar/cervical extension machines from September 26, 2000 through January 25, 2001 be upheld.

Commissioner’s Review

The Commissioner reviewed the documents and arguments presented by Aetna and the IRO. Petitioner’s application for external review did not contain any specific arguments or issues of dispute. In addition, the Petitioner had the opportunity to submit additional documentation for review, but no records were presented. As a result, the Commissioner must rely on the analysis and conclusion of the IRO. The Commissioner therefore concurs with the IRO’s assessment of this case that the physical therapy using the MedX lumbar/cervical extension machines is “investigational” treatment.

V
ORDER

It is ORDERED that the final adverse determination of Aetna Life Insurance Company is upheld. Aetna is not required to cover the physical therapy using the MedX lumbar/cervical extension machines from September 26, 2000, through January 25, 2001.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.