Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain. 
Treatment: Pain Injection in the Spine times (x)1. 

The health plan denied the requested service for the pain injection in the spine x 1. 
The health plan's determination is upheld. 

The patient is a female who has been diagnosed with neck pain. There is a letter of appeal from the treating provider stating that the patient was wrongfully denied for a cervical epidural injection. It was noted that the patient received an epidural injection with 12 months of relief. The patient has disc herniations throughout her entire cervical spine as confirmed by radiological evidence on diagnostic imaging reports. She has also tried trigger point injections and efficacy was 2 weeks of duration. She has completed 12 weeks of conservative management with no improvement and cannot keep taking over-the-counter medications for pain because chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) results in the increase of peptic ulcer disease, acute renal failure and stroke infarction. The patient is struggling with everyday activities. The next step would be to repeat a cervical epidural injection as this is the only management that has provided her with 12 months of relief. 

The magnetic resonance imaging (MRI) of her cervical spine revealed cervical vertebrae (C)3 - C4, C-4 - C-5, C-5 - C6 and C6 - C7 disc herniations deforming the thecal site and abutting the spinal cord with C4 - C5 - C6 - C7 bilateral neural foraminal extension abutting the exiting nerve roots bilaterally. The MRI also revealed C4 - C5 - C6 - C7 disc degeneration and paracentral osseous hypertrophic changes, C3 - C4 right neural foraminal narrowing and C-4 - C-5 - C6 - C7 bilateral neural foraminal narrowing in conjunction with facet and uncinate hypertrophic changes. The MRI also showed C3 - C4 mild central spinal stenosis in conjunction with posterior ligamentous hypertrophy and a C2 - C3 disc bulge. 

The progress report notes the patient was seen for a follow-up visit regarding neck pain described as radiating and she rated her pain level at 5 to 6 out of 10. It was reported that the patient has received epidural injections with greater than 50 percent (%) relief. The patient has been taking oral NSAIDs without improvement and has difficulty with activities of daily living. The patient's current medications are listed as Paroxetine and Ibuprofen. Her physical examination revealed tenderness and trigger points throughout the cervical region bilaterally and palpable tenderness over the C3, C4 and C5 spinous process. The patient has decreased cervical range of motion. Her reflexes were normal bilaterally in the upper extremities and her motor strength was 5 out of 5 bilaterally. Her sensation was normal in the upper extremities. The Spurling's test was positive to the right with neck pain radiating down the upper extremity. The cervical facet loading test was positive bilaterally. The plan was to perform a right sided C7/thoracic vertebrae (T)1 and or laminar epidural steroid injection, stating that the patient had greater than 50% improvement after the last injection. 

The patient is noted to have complaints of persistent neck pain interfering with her activities of daily living and is noted to have documented failure of conservative treatment including medications. However, the policy specifically notes that continuation of injections beyond 12 months or more than 4 injections is considered not medically necessary because effectiveness and safety has not been established. While it is noted the patient has multiple disc herniations in the cervical spine, there was no documentation of radiculopathy on exams such as diminished motor strength, sensation, or reflexes in a specific distribution. There are no exceptional circumstances to support proceeding with ongoing injection therapy beyond 12 months.