Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain
Treatment: facet joint injections
The insurer denied facet joint injections.
The determination is upheld.

This is a male patient diagnosed with neck pain. Records show that a request for diagnostic cervical facet injections was denied as the patient had these injections before and additional injections are not a covered benefit. Records also do not show that the patient has tried and failed at least 6 weeks of chiropractic, physical therapy or prescribed home exercise program.
There is an appeal stating the patient had physical therapy (6 sessions) that was not effective. The patient is participating in a home stretching regimen. The patient had cervical facet radiofrequency on the left and since it has been greater than 2 years since the ablation, their physicians require starting over with diagnostic facet injection to confirm the pain is still related.
The patient was seen for a follow-up visit complaining of pain in the neck rated at 8/10 on the left side. It was stated that the patient had completed 6 visits of physical therapy without benefit. The patient was stable on Tramadol and tizanidine. The patient was participating in a home exercise program. The physical examination revealed limited painful range of motion. 5/5 strength in the upper extremities, positive facet loading to the left. The plan was to perform a diagnostic cervical facet injection at discectomy cervical (C)4 and C5 with sedation. It was noted that the patient had previously responded very well to left cervical radiofrequency ablation but this was last performed several years ago. It provided 100 percent (%) relief and symptoms for greater the 6 month and given it has been more than 2 years since his diagnostic cervical facet injections is imperative that they start with 2 diagnostic blocks before proceeding with radiofrequency ablation to confirm his pain is still the result of spondylosis. It was noted they were unable to proceed with radiofrequency unless the diagnostic facet injections have been within 2 year timeframe which they have not in this case.
At issue is the medical necessity of facet joint injections.

The requested health service/treatment of facet joint injections are not medically necessary for this patient.
The health plan notes that "up to two" diagnostic medial branch blocks/facet injections can be performed when there is failure of conservative treatment, intermittent or continuous neck or back pain interfering with activities of daily living lasting for greater than three months, clinical findings suggest facet joint syndrome and imaging studies suggest no other obvious causes for the pain, and radiofrequency ablation is being considered. In this case, the patient has a history of chronic neck pain interfering with activities of daily living, the patient has failed physical therapy and medications, and imaging studies show no other obvious causes for the patient's pain. It was noted however the patient has previously undergone 2 diagnostic medial branch blocks/facet injections with a positive response and subsequently underwent radiofrequency ablation with 100 percent (%) relief that appears to have lasted for nearly 2 years. There is no need to repeat the procedure as the patient's complaints, exam findings and imaging studies suggest the facet joint as the primary pain generator. Repeat diagnostic blocks are not needed given the positive response to the previous blocks as well as subsequent radiofrequency ablation.