Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain injection
The health plan denied: Pain injection 
The determination is: Upheld. 

The patient is a male who was diagnosed with back pain and was recommended to undergo an interlaminar (lumbosacral joint) L5/S1 epidural steroid injection. His recent imaging and the records did not show that he has tried and failed all conservative therapies to relieve pain before resorting to injections, including at least 3 weeks of certain medications for pain and swelling and at least 6 weeks of changing activity levels. 
The provider states that the patient has been diagnosed with lumbar radiculopathy at L5 and would significantly benefit from an interlaminar L5/S1 epidural steroid injection to alleviate pain. It was noted on the patient's office visit that there was a disc bulge on the patient's magnetic resonance imaging (MRI) scan at the L4/L5 and L5/S1 levels. An electromyography (EMG) test showed a mildly abnormal study with evidence of left L5/S1 radiculopathy.
Prior to seeking approval for injections, the patient has also tried conservative therapies including medications (gabapentin and acetaminophen), working with physical therapy, and adjusting his activity level accordingly to compensate for the back pain that he is experiencing.
An MRI scan of his lumbar spine revealed no significant disc bulge, spinal canal stenosis, lateral recess, or neural foraminal narrowing at any level of his lumbar spine. He was prescribed cyclobenzaprine at his last visit and had no benefit from it. Cyclobenzaprine was discontinued and he was switched to methocarbamol, which helped, but caused sedation. He was also prescribed prednisone for a week. His current medications include gabapentin, acetaminophen, and methocarbamol. On physical examination there was limited lumbar flexion and extension. His strength was intact in all extremities. Lumbar facet loading was positive bilaterally. 
At issue is the medical necessity of the outpatient procedure (injection in spine).
The health plan's determination of medical necessity is upheld, in whole.
The requested health service/treatment of the outpatient procedure (injection and spine) is not medically necessary for this patient. According to the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Epidural corticosteroid injection may be indicated when all of the following are present : radicular pain, duration of greater than or equal to 4 weeks, and 1 or more of the following: lumbar radiculopathy by history (for example, radiation of pain and numbness along the distribution of the affected spinal root), and all of the following: diagnostic imaging (such as computed tomography scan or MRI) correlates with symptoms, failure to respond to greater than or equal to 4 weeks of conservative care, as indicated by all of the following: nonsteroidal anti-inflammatory drug (NSAID), or contraindication to NSAID use; physical therapy, or documentation of patient intolerance to physical therapy".
The patient's physical examination shows no objective findings of radiculopathy with normal motor strength, sensation, and reflexes. The MRI submitted for review showed a normal MRI with no significant disk bulge, spinal canal stenosis, lateral recess, or neural foraminal narrowing at any level of lumbar spine.
There are no objective findings of radiculopathy either on examination or imaging studies that would support this injection. Additionally, the policy requires at least 6 weeks of chiropractic treatment, physical therapy, or prescribed home exercise program and it was noted the patient had physical therapy for less than 6 weeks with no documentation of nonsteroidal anti-inflammatory drugs taken for at least 3 weeks. The provider states that the patient modified his activity but does not identify it as occurring for greater than 6 weeks. Given the above, the requested injection is not medically necessary.