Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Pain Management

Diagnosis: Degenerative Disc Disease
Treatment: Epidural Spinal Injection
The insurer denied the epidural spinal injection.
The health plan's determination is upheld.

The patient is a female who is diagnosed with spine disorder. Records show that a request for lumbar epidural injection was denied as there was no documentation that the patient had pinched nerves on magnetic resonance imaging (MRI).
There is a letter of appeal from the provider stating that the patient had previous treatment such as physical therapy with minimal relief are greater than three months, massage, and chiropractic treatment with minimal relief for greater than three months. The patient has low back pain radiating to the right lower extremity that is described as sharp and shooting with numbness and tingling. The patient's pain is interfering with daily activities and the provider is requesting reconsideration for approval noting they have attached the most recent lumbar MRI.
The MRI of the lumbar spine revealed degenerative disc disease at lumbar vertebrae (L)2-L3 through L5 -sacral vertebrae (S)1, were set all five - S1 with moderate to severe disk space narrowing and endplate marrow signal changes which has progress. Degenerative facet hypertrophy at L4 - L5 and L5 - S1. Disc bulges L2-L3 through L5 - S1. There was no central canal stenosis and moderate bilateral foraminal stenosis L5 - S1, progressed.
The patient was seen for follow-up visit with complaints of low back pain radiating to the right lower extremity with numbness and tingling, rated at 8 out of 10. The patient previously underwent lumbar radiofrequency ablation with reports of 80 percent (%) relief. Current medications include Bupropion, Montelukast, Pantoprazole, Gabapentin, Budesonide-Formoterol, Symbicort, Albuterol, Baclofen, Gabapentin and Lidoderm patch. The lumbar examination revealed limited range of motion, positive spasm and tenderness. The straight leg raise was positive on the right. Lower extremity motor strength was 5 out of 5, sensory examination was intact. Reflexes were 1 plus (+) at the right knee, 2+ on the left and ankle reflexes were 2+ on the right and 1+ on the left. The patient was recommended for a lumbar epidural steroid injection at the right L5 and S1 and given prescriptions for medication.

The requested health service/treatment of pain management services/epidural steroid injection, 2 units is not medically necessary for this patient. Per evidence based Official Disability Guidelines (ODG) guidelines, epidural steroid injections can be considered when there is evidence of radiculopathy on examination with neurological deficits in a specific dermatomal/myotomal distribution, corroborative findings on imaging studies or electrodiagnostic testing, failure of conservative treatment for at least six weeks to include exercise, physical therapy/chiropractic treatment, and appropriate medications such as nonsteroidal anti-inflammatories, muscle relaxants, and/or adjuvant neuropathic medications such as antidepressants or anticonvulsants. There should be evidence of active rehabilitation in association with injection. Records indicate the patient complains of back pain with right lower extremity numbness and tingling. However, there were no specific objective findings of radiculopathy in a specific distribution on exam and no findings of nerve root impingement on MRI to support the requested injections.

The health plan's determination of medical necessity is upheld in whole.