Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbar Radicular Pain
Treatment: Lumbar Steroid Injections
The health plan denied the requested lumbar steroid injections. The health plan's determination is upheld.

The patient is a female with lumbar radicular pain. Epidural steroid injections were performed. The following is not reported in the records submitted for review: history/physical examination, diagnostic study results, procedure notes or response to the procedures performed.

The health plan's determination regarding the proposed health service or treatment is upheld, in whole.

No, based on the submitted material, and peer-reviewed medical literature, the epidural steroid injection is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

Guidelines issued by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine state (in part) "Epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy. Shared decision making regarding epidural steroid injections should include a specific discussion of potential complications, particularly with regard to the transforaminal approach. Transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before injecting a therapeutic substance; image guidance may be considered for interlaminar epidural injections" [1]. Guidelines issued by the American Society of Interventional Pain Physicians state (in part) "The evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis. For axial or discogenic pain, the evidence is fair for either caudal epidural or lumbar interlaminar epidural injections with or without steroids. The evidence is limited for transforaminal epidural injections. For spinal stenosis, the evidence is fair for caudal and interlaminar injections and limited for transforaminal epidural injections with or without steroids. For post-surgery syndrome the evidence is fair for caudal epidural injections with or without steroids. Thus, for disc herniation, one of the 3 approaches may be used; for axial or discogenic pain, either lumbar interlaminar or caudal epidural injections are recommended; for spinal stenosis any of the 3 approaches may be performed, however with transforaminal, there is limited evidence; and for post-surgery syndrome, the preferred modality of treatment is with caudal epidural with or without steroids" [2]. Guidelines issued by the North American Spine Society state (in part) "Transforaminal epidural steroid injection (ESI) is recommended to provide short term (2-4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy" [3].

In this case, there is insufficient clinical material (history, physical examination, imaging studies, etc.) to establish medical necessity for epidural steroid injection. The response to multiple epidural steroid injections is not reported, therefore repeat injections are not considered medically necessary.