Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Lower Back Pain.

Treatment: current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The insurer denied coverage for current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The denial is upheld.

This is a male with a history of lower back pain. He presented to the pain management physician's office for the evaluation of back pain. Imaging of the lumbar spine revealed no evidence of pathology. The patient tried and failed physical therapy (PT) and pain medications for months. The patient had a provocative discography, discogram, and fluoroscopy procedure as a diagnostic test. 

The discogram was a diagnostic study proposed to assist in diagnosis of discogenic spine pain. It provided objective evidence of pain provocation to the specific level of pathology. It would help the surgeon define what level to perform surgery. 

A literature search was performed with the key word of discogram. It is important to note the American College of Radiology did not have a listing for discogram as a current procedure. The Official Disability Guidelines and Milliman Care Guidelines did not reference discogram as a current procedure. The AIM (American Imaging Management) Guidelines did not list discogram as a current procedure. References were found describing the discogram, but they note it is not currently standard of care. It was used in the past and had problems regarding false positives. It was invasive and complications could occur. 

It is important to recognize the references submitted by physician were from years ago. Technology has advanced where imaging studies are more sensitive. It also is important to note in this clinical case, the official radiographic report of MRI (Magnetic Resonance Imaging) was normal. 

The text Stat Pearls (see below) provides an additional explanation.

The carrier's denial of current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code Q9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59 should be upheld. It is not more beneficial than any other standard treatments.