Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and Midback Pain
Treatment: Pain injections (62321 x 1) in spine
The insurer denied pain injections (62321 x 1) in spine
The determination is upheld.

This a female patient with a diagnosis of neck pain. The patient was recommended to undergo thoracic (T) 5-T6 interlaminar epidural steroid injection, which was denied by the health plan as the patient has already been treated for 12 months and had 4 injections and continuation of injections beyond 12 months or 4 injections within 12 months is not covered. It was noted that the initial injection was completed at the same level now being requested. The policy notes that "continuation of injections beyond 12 months or more than 4 therapeutic injections is considered not medically necessary because effectiveness and safety have not been established."

Per a progress note, the patient was seen via a telemedicine visit for an acute flareup of underlying chronic neck and mid back pain. It was noted the patient had bilateral cervical (C) 5 and C6 medial branch blocks reporting 80 percent (%) pain relief lasting for 2-3 hours. The patient previously had lumbar medial branch blocks and radiofrequency ablation. She had a C7-thoracic (T) 1 interlaminar epidural steroid injection reporting 80% pain relief lasting thus far and was able to perform activities of daily living with less pain and better range of motion. The patient had a T5-T6 interlaminar epidural injection with 80% pain relief lasting for 5 months and increased ability to sit and stand for longer. Currently, the thoracic/mid back pain is rated at 8/10 and radiates to the bilateral axillary and rib cage region. The patient reports numbness and tingling since a total C4 disc replacement. The neck pain is rated at 6/10 and radiates to the bilateral trapezius, shoulders, jaw and teeth. The patient complains of muscle spasm in the cervical paraspinals, trapezius and rhomboid region and complains of mid back pain and tenderness. Lower neck and axial pain is predominant. The patient reports she gets massage treatments that times that temporarily helps slightly with the pain. She has had 4 injections and according to her insurance guidelines a patient can only have 4 in a year so they will wait until after that date for further injections. It was noted that she also had T5-T6 interlaminar injections. The patient underwent C7-T1 interlaminar epidural steroid injections. Electrodiagnostic studies showed evidence of chronic bilateral C6 and left C7 radiculopathy. Cervical spine magnetic resonance imaging (MRI) showed C-5-C6 and C6- C7 left uncovertebral spurring. C7-T1 small diffuse bulging annulus versus disc protrusion. On physical examination, there was worse pain with rotation and extension; right-sided thoracic paraspinal tenderness; negative facet loading bilaterally; tenderness at the left T3-T4 and T4-T5; lower extremity motor strength, sensation, and reflexes were normal; upper extremity motor strength, sensation, and reflexes were normal. The patient was noted to have trigger points present at the bilateral cervical paraspinal muscles and trapezius. The plan was to continue with medications including oxycodone, amitriptyline, Celexa, cyclobenzaprine. It was noted the patient would be recommended for C7 - T-1 cervical interlaminar epidural injection. The provider states that the patient completed a physician directed home physical therapy program for greater than 6 weeks. The patient was also recommended for lateral C5-C6 cervical medial branch blocks and a lumbar epidural steroid injection. At issue is the medical necessity of pain injections in spine.

The requested health service/treatment of pain injections in spine is not medically necessary for this patient. Records provided indicate the patient has a history of chronic cervical, thoracic and lumbar pain and has been undergoing repeated injections for many years now throughout the spine. The provider requested a cervical epidural injection at C7-T1 and it is noted the patient previously had injections at this level. The prior denial was noted to be for a cervical epidural injection at T5-T6 and the patient has also had T5-T6 interlaminar injections. There were no objective findings of radiculopathy on examination and no findings of disc herniation or never compromise on MRI at this level. The policy notes that "continuation of injections beyond 12 months or more than 4 therapeutic injections is considered not medically necessary because effectiveness and safety have not been established." The patient has been receiving injections for much longer than 12 months and therefore medical necessity is not established.