Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Radiology Services 
The insurer denied outpatient procedures (facet joint injections). The denial is upheld. 

The patient is a female diagnosed with left low back pain. There is a final adverse determination denial notice letter noting that the request for facet injections remains denied, as records did not show failure of at least six weeks of conservative management such as physical therapy and activity modification. According to the information submitted, the patient has only attended physical therapy for three and half weeks.

In the progress note, the patient was noted to have complaints of left low back pain and left elbow pain. Pain radiates to both forearms, left buttock and posterior left thigh. Pain is rated at 8/10. Treatment history states she was treated by her physical therapist, which helped somewhat. Medications alleviate symptoms somewhat. Current medication includes Neurontin and naproxen. Physical examination revealed tenderness and tight muscle band at the left vertebral muscles and left sacral sulcus. There was restricted lumbar range of motion secondary to pain. Motor and sensory exam was intact, reflexes were normal. Positive sitting straight leg raise on the left. Positive facet loading on the left and positive pelvic rock test bilaterally. Plan was for tendon injections and medial branch blocks. It was noted the patient would continue with physical therapy. The subject under review is the medical necessity for the outpatient procedures - facet joint injections.

The health plan's determination is upheld in whole.

No, the requested Outpatient procedures (facet joint injections) are not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), facet injections/medial branch blocks can be considered when there is objective examination findings consistent with facet mediated pain, Absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. If a diagnostic medial branch block is performed, this should be performed at no more than two joint levels. There should be no history of prior fusion at the levels to be performed and imaging studies should rule out other obvious causes for the pain (such as fracture, tumor, infection, or significant extraspinal lesion). Medial branch blocks should only be performed when radiofrequency facet neurolysis is being considered.

Records provided indicate the patient has a history of chronic back pain and reports pain radiates down the left buttock and posterior thigh. On examination there was positive straight leg raise testing. Radicular symptoms are exclusionary criterion for undergoing facet procedures. There was no indication that the provider plans to pursue radiofrequency ablation. The requested facet joint injections are not medically necessary.