Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Pain Injection (transforaminal epidural steroid injection). 
The insurer denied the pain injection (transforaminal epidural steroid injection). 
The determination is upheld. 

The patient was diagnosed with low back pain. There is a handwritten note of appeal stating that they requested a right L (lumbar) 5 and S (sacral) 1 transforaminal injection and this means L5 AND S1 which is two levels. The injection that was approved only covers L5 level and they need an additional level to cover S1. 

A progress note shows that the patient was seen with complaints of low back pain and severe right lower extremity sciatica. It was noted that she completed eight weeks of physical therapy without benefit. The pain is rated at 5/10 and she complains of a lot of neuropathic symptoms in the foot making it difficult to ambulate as well as a pins and needles sensation following the L5 distribution but occasionally posteriorly in the S1 distribution. She currently uses ibuprofen and also took a Medrol Dosepak which almost entirely relieved her symptoms but this was short-lived. She has had massage and has used heat and a brace. The physical examination revealed that the sensation was grossly intact in the lower extremities bilaterally, motor strength was 5/5 bilaterally, reflexes 1 plus (+) and equal. There was exquisite tenderness at the right sciatic notch and positive straight leg raise on the right. The range of motion was limited. The plan was for a right-sided L5 and S1 transforaminal epidural steroid injection. There is a final adverse determination notice noting that the health plan approved a transforaminal epidural steroid injection at the right lumbar (L) 5/sacral (S) 1 level (current procedural terminology (CPT) code 66483) with partial denial of CPT code 64484 as the requested injection was for two levels and the clinical notes only show the need for injection at one level. At issue is the medical necessity for pain injection (transforaminal epidural steroid injection). 

The requested health service/treatment of pain injection (transforaminal epidural steroid injection) is not medically necessary for this patient. Per the 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. Epidural injection is not a stand-alone procedure. There should be evidence of active rehabilitation in association with injection. Records indicate the patient has complaints of back pain with sciatica in the L5 distribution and occasionally in the S1 distribution. However, motor strength, sensation, and reflexes were normal with no objective findings of radiculopathy in a specific distribution on exam. There were no imaging studies submitted for review to corroborate radiculopathy. The requested epidural steroid injection is not medically necessary.