Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography angiography (CTA), facet joint injections and nerve blocks for treatment of the enrollee, who has a history of degenerative disc disease and neck pain. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The American College of Radiology states that CTA may be indicated if spinal arteriovenous malformations or dural arteriovenous fistulae are considered to be likely causes of slow progressive myelopathy and may also be useful in evaluating the intra-cranial  and extra-cranial blood vessels for patients with sudden development of a single focal neurological deficit suggesting a vascular ischemic event such as an infarction. This patient presents with significant pain in the craniocervical junction with bilateral greater occipital neuralgia type discomfort, severe headache, and numbness and tingling radiating into her bilateral arms. The records submitted along with the brain imaging evidence do not demonstrate clinical signs/symptoms consistent with a vascular ischemic event or infarction. Nor are there clinical signs/symptoms or imaging evidence consistent with progressive myelopathy. As such, there is no compelling rationale presented to support the medical necessity of CTA for evaluation of this patients medical condition. Regarding facet joint injections, the medical evidence for cervical intraarticular injections with local anesthetic and steroids is limited. The patient has undergone facet steroid injections without significant or sustained relief. There is no compelling rationale presented to support the medical necessity of additional facet joint injections. Therefore, the requested facet joint injections are not medically necessary for treatment of this patient. As for the requested nerve blocks, there is a lack of peer reviewed literature to support the medical necessity for the requested nerve blocks. Recent evidence from the U.S. Food and Drug Administration Anesthetic and Analgesic Drug Products Advisory Committee does not recommend epidural steroid injections (ESI) in the cervical region. They concluded that injecting a particulate steroid in the cervical region, especially using the transforaminal approach, increases the risk for sometimes serious and irreversible neurological adverse events, including stroke, paraplegia, spinal cord infarction, and even death. ESIs are not recommended higher than the C6/7 level. No cervical interlaminar ESI should be undertaken at any segmental level without pre-procedural review, and particulate steroids should not be used in therapeutic cervical transforaminal injections. This patient presents with persistent severe neck pain with numbness, tingling and weakness in the both hands that has been refractory to conservative treatment. There is imaging evidence of a high intensity zone at C6/7 with prior artificial disc replacement at C5/6. There were reported CT scan findings of slight subluxation at the C1/2 joint and disc dehydration and signal intensity at C2/3. A request has been submitted for a C2 nerve root block. There is no imaging or electrodiagnostic evidence of nerve root compression consistent with C2 radiculopathy. Therefore, the requested nerve block is not medically necessary for treatment of this patient. For the reasons stated above, the requested computed tomography angiography (CTA), facet joint injections and nerve blocks are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.