Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain injections (64483 x 1, 64484 x 1)
The insurer denied the pain injections (64483 x 1, 64484 x 1).
The health plan's determination is upheld.

The patient is a female who was diagnosed with back pain. The records show that a request for selective nerve root block/epidural steroid injection was denied by the insurance carrier as the records did not show that the patient had severe pain from a slipped disc at a specific spine level or narrowing of the spinal canal confirmed by physical examination and imaging and injections are only covered for one level of the spine on both sides or for two levels of the spine on one side.

On a letter from the treating provider, it was noted that the patient needed the bilateral transforaminal epidural steroid injection for the treatment of pain in the sciatic nerve. The patient's pain started more than 5 years ago without trauma. The patient has tried and had no relief from physical therapy, chiropractic, acupuncture and medial branch blocks. She has also failed numerous anti-inflammatories and nerve pain medications. She continues to have increased pain. During their last visit it was discussed to try and epidural injection as she has had successful sets of epidural injections in the past with over 80 percent (%) pain relief. She is now unable to sit or stand for long periods of time due to constant radiating pain and wants to proceed with the injections.

There is an appeal stating that the patient reports that due to her pain she can barely stand. Her pain is constant. She reports the pain is increasing and if she stands for too long it increases. She takes her medications with minimal relief and reports it can take the edge off. After her previous injection she could stand for long periods of time and pain wasn't as constant as now. It was noted they need approval for this injection so the patient can perform routine activities without the pain.

The magnetic resonance imaging (MRI) of the lumbar spine revealed markedly degenerated diffusely bulging disc at lumbar vertebrae (L)5 to sacral vertebrae (S)1 with moderate bilateral foraminal compromise, progressed from prior study. However, the right disc herniation with inferior migration has resolved. There is diffuse disc bulge at L2-L3 with broad-based left-sided protrusion with mild to moderate left foraminal compromise progressive from the prior study. Additional minor findings at L3 - L4 and L4 - L5 were stable.

A progress report notes that the patient had complaints of low back pain radiating down the legs to the feet rated at a 9 out of 10, right worse than left with a burning feeling and her right foot gets numb. It was noted the patient was seen via telehealth. It was reported she has tried "various epidurals in our office with little to no relief." She had a radiofrequency ablation that she felt provided 40% pain relief for about 2 to 3 months. The patient's pain is located in the low back radiating down the bilateral back of the leg to the sole of the foot. A physical examination was not performed. The plan was to obtain authorization for transforaminal epidural steroid injection at bilateral L5 to S1.

Records indicate the patient has chronic back pain with sciatica. However, the most recent progress note was via telehealth and did not include a physical examination showing radiculopathy. Additionally, it was reported she has tried "various epidurals in our office with little to no relief." Repeat injections are only supported at a single level bilaterally or up to 2 levels unilaterally and there must be at least 50% pain relief and functional improvement lasting for at least 2 months. Although the letters of appeal state that the patient add up to 80% pain relief, this is not consistent with the actual progress notes/medical record which states that the patient had "little to no relief" from prior injections.