Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Cervical interlaminar epidural steroid injection
The insurer denied the cervical interlaminar epidural steroid injection.
The determination is upheld.

This is a patient who was diagnosed with back pain. Records show that a request for cervical epidural steroid injection was denied as the records did not show the exact spine level being requested for treatment and injections are only covered for one treatment level of the spine. Records also did not show that the patient had tried and failed all conservative therapies to relieve the pain before resorting to injections including at least 6 weeks of therapy (chiropractic, physical therapy or prescribed exercise program), at least three weeks of certain medications and at least 6 weeks of activity modification.

There is an appeal from the provider stating that the provider is requesting to perform cervical (C) 6-C7 "or" C7-thoracic (T) 1 and it will be determined by the interventionalist the day of the procedure but they will only do one level and not both.

A progress report indicates the patient has a history of neck pain rated at 6/10 that goes into the right upper extremity, "suspicious for a radiculopathy." The pain is rated at 6/10. It was noted she has had extensive physical therapy. She has also tried gabapentin and ibuprofen as well as Tylenol arthritis and has been on these medications for over six months as well as doing activity modification and avoidance of exacerbating activities. She has increased pain with activities and is overwhelmed by her pain. The provider states that they will request specifically C7-T1 interlaminar injection as the insurance carrier will not approve it without a specific level requested. The physical examination revealed positive tenderness at the mid to lower cervical facet joints bilaterally, positive cervical facet grind test bilaterally, positive Spurling's test bilaterally right greater than left, tenderness to the trapezius bilaterally and limited range of motion. There was decreased motor strength at 3/5 with grip strength on the right, 4/5 on the left, elbow flexion and extension 4/5 bilaterally. Sensation was intact and reflexes were equal and symmetric. The plan was to again request C7-T1 interlaminar epidural steroid injection. At issue is the medical necessity of a cervical interlaminar epidural steroid injection.

The requested health service/treatment of cervical interlaminar epidural steroid injection is not medically necessary for this patient. 

Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Conditionally recommended at a level no higher than C6-7 on a case-by-case basis as a short-term treatment for intervertebral disc herniation, degenerative changes, and/or spinal stenosis that results in radiculopathy (defined as irritation or injury to a nerve root that typically causes pain, numbness, and/or weakness in the part of the body that is supplied with the nerves from that root), when used in conjunction with active rehabilitation efforts. 1) Radiculopathy (irritation or injury to a nerve root that typically causes pain and/or numbness or weakness in the part of the body supplied with the nerves from that root) must be well documented, along with objective neurologic findings on physical examination. Acute radiculopathy must be corroborated by advanced imaging studies (eg ["for example"], computed tomography scan, magnetic resonance imaging) and, when appropriate, electrodiagnostic testing, unless documented pain, reflex loss, and myotomal weakness abnormalities support a dermatomal radiculopathy diagnosis. A request for a procedure in a patient with chronic radiculopathy requires additional documentation of recent symptom worsening associated with deterioration of neurologic state. 2) Unresponsive to conservative treatment (eg, exercise, physical therapy, nonsteroidal anti-inflammatory drugs, muscle relaxants, neuropathic drugs)... (i) Interlaminar epidural steroid injection (ESI) is not recommended higher than the C6-7 level. (ii) Transforaminal ESI is not recommended."

Records provided indicate that the patient has complaints of neck pain that goes into the right upper extremity that the provider feels is "suspicious for a radiculopathy." There was noted to be decreased motor strength at 3/5 with grip strength on the right, 4/5 on the left, elbow flexion and extension 4/5 bilaterally. It was noted that the patient has failed conservative treatment including physical therapy and medications as well as activity modification. However, there were no imaging studies or electrodiagnostic reports submitted for review to corroborate findings consistent with radiculopathy. The requested cervical epidural steroid injection is not medically necessary.