Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Pain injections in spine. 

The insurer denied pain injections in spine. 
The determination is upheld. 

The patient was diagnosed with low back pain. A request for a lumbar epidural steroid injection was previously denied as the records did not show what spinal levels are being requested to be injected and injections are only covered for one level of the spine on both sides for two levels of the spine on one side. It also stated that no more than four injections can be given at the same site within 12 months. 

A letter of appeal from the provider states that they are requesting appeal for transforaminal epidural steroid injection to deliver medication close to the nerve root and anterior epidural space at the left lumbar (L) 3 and L4. The provider states the patient has had previous treatment such as physical therapy with minimal relief for greater the 3 months, massage therapy with minimal relief for greater than 3 months and chiropractic treatment with minimal relief for greater than 3 months as well as non-steroidal anti-inflammatory drugs (NSAIDs) for greater than 3 months. On a follow-up visit, the patient complained of sharp shooting pain into the low back radiating to the left leg and reported having difficulty walking. The provider stated that according to their records the patient had not been treated for low back pain before and had not received any treatment for lumbar radiculopathy. The pain was interfering with her activities of daily living and the patient was unable to function. The provider stated that they were attaching the most recent lumbar spine magnetic resonance imaging (MRI) scan and requested approval of the epidural injection. 

A magnetic resonance imaging (MRI) scan of the lumbar spine shows broad-based left foraminal/extraforaminal disc herniation superimposed on annular bulge at L3 - L4 with left L3 nerve root abutment; annular bulge and small superimposed right lateral recess disc herniation at L4 - L5 with impingement upon the right L5 nerve root; annular bulge L5-sacral (S) 1. 

A procedure report shows that the patient underwent a lumbar epidural steroid injection at the left L3 and L4 for lumbar radiculopathy. The patient returned for a follow-up visit status post lumbar epidural injection reporting 70-80 percent (%) sustained relief and was referred for physical therapy. 
The patient returned for a follow-up visit reporting that the low back pain was returning and rated at 6-7/10. The provider performed a repeat left L3 and L4 transforaminal epidural steroid injection. 
The patient returned for a follow-up visit reporting greater than 80% pain relief following the lumbar epidural injection. 
Per a progress report, the patient was seen for follow-up visit with complaints of pain in multiple body parts including the low back radiating to the left thigh. The pain was rated at 9/10. The patient wanted to get an epidural to treat the radiating leg pain. The patient failed physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). Current medications included levetiracetam, olmesartan, Pennsaid topical solution, and lidocaine topical patch. A lumbar exam revealed limited range of motion. There was positive tenderness and spasm at the paravertebral muscles. A straight leg raise was positive bilaterally at 50 degrees (). Motor strength was 5/5 in the lower extremities and sensory exam was intact. Reflexes were 1 plus (+) at the right knee, 2 plus (+) on the left and ankle reflexes were 2+ on the right and 1+ on the left. The plan was to schedule the patient for a lumbar epidural steroid injection at the left L3 and L4. At issue is the medical necessity of pain injections in the spine. 

Records indicate the patient has chronic low back pain with lumbar radiculopathy and examination shows positive straight leg raise bilaterally at 50 as well as diminished reflexes. The lumbar spine MRI shows disc herniations at L3 - L4 and L4 - L5 with impingement of the left L3 nerve root, although the L4 - L5 herniation impinges the right L5 nerve root and is not consistent with the requested levels. Additionally, the patient has previously undergone multiple lumbar epidural injections with reports of 80% pain relief but no indication of duration of at least 2 months improvement or related functional improvement. The provider's letter of appeal states that the patient has never had injections for lumbar radiculopathy, however, there are procedure notes submitted for review showing the patient had multiple lumbar epidural injections. Medical necessity is not established.