Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy Prescription Drugs. 
The insurer denied facet joint injections. 
The denial is upheld. 

The patient is a female. The provider is requesting to perform lumbar medial branch blocks at lumbar (L)3-L4, L4-L5, L5-sacral (S)1, stating the patient has failed 6 weeks of conservative treatment. Records show that these injections were denied and there was a final adverse determination denial letter from the health plan stating that the clinical notes do not clearly show that these injections are in preparation for possible radiofrequency ablation and records did not show that the patient has tried and failed all types of conservative treatment including at least three weeks of medication that decreases inflammation. On appeal, the provider states that the note states the patient has failed 12 weeks of home exercise, pain medication and activity modification. The provider states that after 2 successful diagnostic blocks radiofrequency ablation will be ordered.

The subject under review is the medical necessity for the facet joint injections. 

The requested health service/treatment of Facet Joint Injections are not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, facet injections/medial branch blocks can be considered when there is objective examination findings consistent with facet mediated pain, absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. If a diagnostic medial branch block is performed, this should be performed at no more than two joint levels. There should be no history of prior fusion at the levels to be performed and imaging studies should rule out other obvious causes for the pain (such as fracture, tumor, infection, or significant extraspinal lesion). Medial branch blocks should only be performed when radiofrequency facet neurolysis is being considered.
In this case, the patient is noted to have chronic back pain and there are findings suggesting the facet joints may possibly be a pain generator, although there were also findings on MRI showing possible abutment of the exiting L4 and L5 nerve roots from extraforaminal disc and osteophytes which could potentially be a pain generator. These injections have previously been denied multiple times due to a lack of documentation showing failed conservative treatment such as therapy and medications such as nonsteroidal anti-inflammatory drugs. The provider submitted an appeal stating the patient has failed 12 weeks of home exercise, pain medication and activity modification. However, records provided specifically note that the patient has had "no physical therapy in quite some time. She has had no chiropractic care." Records do not show the patient being prescribed any nonsteroidal anti-inflammatory drugs to reduce inflammation and pain. There are no therapy notes submitted for review. Further, it is noted that the provider indicated they want to perform medial branch blocks with steroids. This would be a therapeutic procedure, not diagnostic as a diagnostic medial branch block would include local anesthetic only to confirm the source of pain. The requested injections are not medically necessary.