Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: Pain Injection: (64490x1; 64491x1; 64492x1)

The insurer denied coverage for Pain Injection: (64490x1; 64491x1; 64492x1)

The denial is upheld.

According to the documentation provided, this is an adult with 8/10 neck pain. The pain has been present for more than 3-4 months. Conservative management including 3 months of physical therapy, 3 months of chiropractic manipulation, 3 months of acupuncture and 3 months of over the counter (OTC) medications have not improved her symptoms. Her pain is interfering with activities of daily living (ADLs) including self care. Focused cervical neck exam showed evidence of pain with facet loading. Previous magnetic resonance imaging (MRI) showed evidence of multi-level cervical disc herniations. the doctor recommended diagnostic cervical medial branch blocks (MBB) to determine if the patient will benefit from radiofrequency ablation (RFA) of the involved nerves. According to the notes provided, the doctor performed an X-ray of the cervical spine prior to performing the MBBs. His notes state that the X-ray revealed multilevel degenerative disc disease and facet arthropathy. An addendum states that on this x-ray there were no signs of fracture, tumor, infection, significant extraspinal lesion or any findings suggesting any other obvious source of pain. There is no official radiology report to support these findings. The health plan has denied payment for the MBBs stating that there must be imaging studies that do not suggest any other obvious cause of pain.

While Centers for Medicare and Medicaid (CMS) does not require imaging studies in addition to clinical assessment, it does indicate that imaging studies often play an important role in the exclusion of other etiologies of back and cervical/thoracic pain. UpToDate states that imaging is indicated for patients with persistent moderate to severe neck pain (eg, lasting >6 weeks and affecting sleep or ability to perform daily activities and/or occupation) even if they lack "red flags". For most of these individuals (eg, without concern for infection or malignancy, no localizing neurologic symptoms or signs, no major trauma), the preferred initial examination is cervical spine radiography. If there are concerning abnormalities noted on cervical spine radiography (eg, endplate erosion and soft tissue swelling raising concern about discitis/osteomyelitis, bony destruction raising concern about metastases, or bony remodeling suggesting underlying mass), cervical spine MRI with contrast should be performed. MRI is generally not indicated if radiographs are normal or show only degenerative changes. Cervical spine radiography or x-ray series typically consists of anterior-posterior (AP) and lateral views.

Based on the documentation provided, this patient meets the CMS recommended criteria for diagnostic facet joint injections. However, given her previous MRI finings of cervical disc herniations and UpToDate recommendations, imaging studies to rule out other sources of pain would be considered medically reasonable and necessary. There are no official radiology reports that indicate that this was done. The denial is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Pain Injection: (64490x1; 64491x1; 64492x1) services is not substantiated.