Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain.
Treatment: Additional pain injections to the spine (62323 x 1).
The insurer denied: Additional pain injections to the spine (62323 x 1).
The denial is upheld.

The patient is an adult male with acute on chronic low back pain. The patient had a L1-2 (lumbar one to two) ILESI (interlaminar epidural steroid injection) 8 months ago with 80% relief of pain and increase in ability to perform ADLs (activities of daily living) for 2 months. The pain is currently a 10/10 without medication. He complains of numbness and difficulty lifting the left leg. He attended physical therapy 4 years ago for 8 weeks and continues physician supervised home exercise program. EMG (electromyogram) from 3 years ago shows an active left L4 (lumbar four) and L5 (lumbar five) radiculopathy. MRI (magnetic resonance imaging) of the lumbar spine from last year shows multi-level disease most severe at L2-3 (lumbar two to three) where there is grade 2 to 3 spinal stenosis. Other past epidurals include: L1-2 (lumbar one to two) ILESI (interlaminar epidural steroid injection), L3-4 ILESI (interlaminar epidural steroid 
injection) 3 years ago times two, L3-5 (lumbar three to five) TFESI (Transforaminal Epidural Steroid Injection) 4 years ago, and L5-S1 (lumbar five to sacral one) ILESI (interlaminar epidural steroid injection) 4 years ago. The request for repeat L1-2 (lumbar one to two) ILESI (interlaminar epidural steroid injection) was denied coverage by the health plan, noting patient has been treated for 12 months already. This denial is being appealed, noting the patient is having an acute flare of lumbar radiculopathy due to spinal stenosis.

The requested additional pain injections to the spine (62323 x 1) s not medically necessary.

It generally would not be considered medically reasonable and necessary for treatment with ESI (epidural steroid injection) to extend beyond 12 months. Use beyond twelve months requires the following:
1) Pain is severe enough to cause a significant degree of functional disability or vocational disability.
2) ESI (epidural steroid injection) provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).
3) Rationale for the continuation of ESI (epidural steroid injection)s including but not limited to patient is high-risk surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with ESI (epidural steroid injection)s for at least three months.
4) The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use. 
While the patient's pain is severe enough to cause a significant degree of functional disability or vocational disability, ESI (epidural steroid injection) provides at least 50% sustained improvement of pain and/or 50% objective improvement in function, it has not been established that Rationale for 
the continuation of ESIs (epidural steroid injection) including but not limited to patient is high-risk surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with ESI (epidural steroid injection)s for at least three months. In this case, the patient did not receive benefit for at least three months from the most recent L1-2 (lumbar one to two) ILESI (interlaminar epidural steroid injections). As such, the requested health service is not medically necessary.