Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested reimbursement for epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient underwent multiple epidural steroid injections at four lumbar spine levels. At the L2-3 level, an interlaminar injection was performed followed by bilateral transforaminal injections at L3-4, L4-5 and L5-S1. A prospective study by Choi and colleagues evaluated the role of epidural steroid injections to treat low back pain. The authors found that epidural steroid injections can decrease the pain and disability in the majority of patients with moderate disability for up to one year. They recommended epidural steroid injection as a first-line treatment in patients with moderate disability. A systemic review and meta-analysis by Manchikanti and colleagues concluded that epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine in conjunction with steroids were significantly effective. In this case, the provider performed a lumbar epidural steroid injection at L2-3, despite a lack of pathology seen at this level. There were no findings of disc herniation, spinal canal narrowing, or neural foraminal narrowing. The physical examination did not report findings consistent with focal neurological deficits at this level. As such, there was no rationale for performing this injection at this level. The other issue is that the interlaminar injection done at L2-3 is expected to spread to levels above and below the level of the injection. In this case, the injection would spread to the L3-4 and possibly L4-5 levels, so there was no medical rationale to perform additional injections at these levels, which is what was done in this case. While epidural steroid injections do have evidence to support their use in lumbar stenosis and lumbar radiculopathy, which this patient has, there is a lack of evidence in the medical literature to support performing two different types of epidural steroid injections on the same patient on the same day. The standard of care is to perform one type of injection at the level of the spine where the symptoms are expected to be coming from.  There is also a lack of evidence to support performance of the injections at lumbar levels where there is no evidence of pathology. The interventional therapy provided in this case is not consistent with current standards of practice. There is a lack of support in the peer-reviewed literature for combining interlaminar and transforaminal epidural steroid injections on the same day in the same area of the spine. Therefore, epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16 were not likely to have been more beneficial than other treatment options.