Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain management; pain injections to the joints between spine and hips
The insurer denied the Pain management; pain injections to the joints between spine and hips.
The determination is upheld.

This is a patient diagnosed with low back pain. There is a final adverse determination denial letter showing that sacroiliac joint injections were denied as records did not show the patient had low back and thigh pain below a certain level of the spine interfering with daily activities for at least three months, did not show that the patient had tried and failed treatments that are less invasive including all of the following: at least 6 weeks of physical therapy, at least 3 weeks of certain medications to treat pain and swelling, and at least six weeks of activity modification. Magnetic resonance imaging (MRI) also shows that there may be some other disc or spine problem causing the pain.
There is a handwritten appeal note from the patient stating that she injured her back from a fall. She went to see a pain doctor and was prescribed steroids, pain medications, muscle relaxers and prescription for physical therapy. She reports she completed three weeks of physical therapy and left there feeling worse. Pain switched from her low back to buttock and down her right leg.
Per a progress note, the patient was seen for a follow-up visit regarding low back pain. The patient had a right lumbar (L) 4 and L5 transforaminal epidural injection done followed by a right sacral (S) 1 transforaminal epidural injection . The right sacroiliac (SI) joint injection was denied. It was noted the patient has a history of back pain as well as pain in the gluteal and sacroiliac region right greater than left. The pain was described as aching and throbbing in the lower half of the right leg and radiating to the right foot, right knee and right thigh, backside of the right leg to the ankle. The pain was rated at 4/10. She has tried ice, heat, and chiropractic manipulation with mild relief. Current medications include Flexeril, gabapentin, Mobic, a heating pad, ice pad, over-the-counter (OTC) Tylenol and OTC Biofreeze. It was stated that the patient has tried chiropractic and goes every couple weeks with little to no relief and currently is on hold, the patient had six visits of physical therapy  but had to stop as it made the pain worse. The patient had lumbar epidural injections with right lumbar (L) 4 - L5 with 80%(percent) relief and a right S1 transforaminal epidural injection with 100% relief. The physical examination revealed decreased range of motion to the lumbar spine with flexion and extension. There was tenderness to palpation at the bilateral lumbosacral paraspinals and right SI joint, positive lumbar facet challenge, sensation is intact in the lower extremities and reflexes were 1 plus (+). There was positive right-sided Fortin's sign, Faber test, compression test and distraction test of the sacroiliac (SI) joint. It was stated that the patient has low back pain and radiculopathy as well as right-sided sacroiliitis. It was noted the plan was to restart physical therapy again with a home exercise program, hold chiropractic, continue gabapentin and again recommended she undergo and SI joint injection stating she has failed all modalities for over six weeks.
At issue is the medical necessity of pain management; pain injections to the joints between spine and hips.

No, the requested health service/treatment of pain management; pain injections to the joints between spine and hips is not medically necessary for this patient.
Evidence-based guidelines note that sacroiliac joint corticosteroid injections are recommended as a treatment option for patients with a specific known cause of sacroiliitis, i.e., proven rheumatologic inflammatory arthritis involving the sacroiliac joints with symptoms of sacroiliitis of at least 1 to 2 months duration with prior treatment that has included nonsteroidal anti-inflammatory drug (NSAIDs). Sacroiliac joint injections are not recommended for chronic non-specific low back pain, including pain attributed to the sacroiliac joints, but without evidence of inflammatory sacroiliitis (rheumatologic disease) or any radicular pain syndrome. There are no quality studies showing a long-term improvement in pain or function in those receiving sacroiliac joint injections for chronic non-specific lower back pain (LBP). In this case, there is no evidence that the patient has proven inflammatory sacroiliitis (rheumatologic disease). In this case, the patient is noted to have chronic back pain with radiculopathy. The patient had lumbar epidural injections with right L4 - L5 with 80% relief and right S1 transforaminal epidural injection with 100% relief. It was noted that the patient previously completed six visits of physical therapy. The patient has not had at least six weeks of physical therapy for this condition and now that the pain is much better controlled (due to lumbar epidural injections) the patient is being referred to restart physical therapy. The provider references a magnetic resonance imaging (MRI) of the lumbar spine showing lumbar facet arthropathy as well as multiple lumbar disc herniations which appear to be the cause of the patient's pain. There are no findings related to the SI joints suggesting the patient to have inflammatory sacroiliitis.
The requested sacroiliac joint injections are not medically necessary.