Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbosacral radiculopathy
Treatment is pain injection (64483 x 1, 64484 x 1) services
The insurer denied coverage for pain injection (64483 x 1, 64484 x 1) services
The denial is overturned

The patient had Epidural steroid injections with good lasting effect. Then, the patient had a right L (lumbar)5 and S (sacral)1 transforaminal epidural steroid injection (ESI). There was 60% (percent) improvement in pain. The patient was still in discomfort and not at baseline. The physician recommended right L4 and L5 transforaminal ESI. 
	
This patient had a positive but incomplete response to the Epidural steroid injections. Mattie "et al" (and others) suggested repeating the injection:

"When patients have a positive but incomplete response to an initial ESI, the published evidence suggests that a repeat ESI is reasonable. ESIs may also be repeated to reinstate previous treatment benefit that subsequently diminished. Although a two-week interval between injections may be a reasonable balance of risk vs (versus) benefit, there is no direct evidence that distinguishes this exact time point as optimal. There is no evidence to support administering a series of ESIs irrespective of the clinical response to an initial injection.

The decision to repeat an ESI is dependent on: providing sufficient time to assess the response to a first ESI;
And allowing for recovery from adverse systemic effects of steroid administration.

Hypertension and hyperglycemia effects are generally limited to two to three days, HPA (hypothalamic-pituitary-adrenal) axis, if present, may occur for three weeks or longer, and these effects may be dependent on steroid type and dose.

Variable risk/benefit ratios for each individual patient, as the presence of comorbid diabetes mellitus, osteopenia/osteoporosis, endocrinopathies, high surgical risk, and a range of other factors may influence the threshold to provide vs (versus) withhold additional injections."

Standardized, nationwide LCDs (local coverage determinations) have been published regarding the use of Epidural steroid injections. They specifically state:

Use beyond twelve months requires the following:

Pain is severe enough to cause a significant degree of functional disability or vocational disability, the ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline), rationale for the continuation of ESIs including, but not limited to, the patient is a high-risk surgical candidate, the patient does not desire surgery, and recurrence of pain in the same location relieved with ESIs for at least three months.

Here the patient has continuing pain after 18 months. Prior injections have provided greater than 50% pain relief and the pain is in the same location which was relieved with ESIs for at least 3 months.

The requested procedure is medically reasonable and necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for pain injection (64483 x 1, 64484 x 1) services is substantiated.