Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: pain management (injections)
The insurer denied pain management (injections)
The determination is upheld.

This is a male patient diagnosed with back pain. There is a letter of appeal stating that an appeal is requested for the patient's epidural injection which was not done and states they are including records including a copy of the patient's letter, medication history, magnetic resonance imaging (MRI), x-ray and clinical notes.
There is a copy of a letter from the health plan to the provider that requested additional information be submitted and it appears the provider has responded to this with handwritten notations on the original letter indicating that they are requesting to perform the bilateral sacral (S) 1 nerve root injection. It was stated that the patient previously had this injection several months ago at lumbar (L)5 - S1. It was stated the patient has tried all (referencing failed conservative treatment) without relief.
The patient was seen for a follow-up visit with complaints of low back pain radiating to the right leg described as moderate to severe. It is noted that the patient has had injections which "provided minimal relief." The patient also reports numbness and tingling into the right foot. Medication list includes oxycodone - acetaminophen, oxycodone, cyclobenzaprine, levothyroxine, omeprazole, losartan, amlodipine, hydrochlorothiazide, and prednisone. On physical examination, there was tenderness to palpation of the lumbar paraspinals, gluteals and iliolumbar ligament bilaterally. Range of motion was limited. Lower extremity motor strength was 5/5 bilaterally other than "weak bilateral foot dorsiflexors not further quantified. Straight leg raise was positive on the right. Sensation was reduced in the feet and no specific distribution. It is noted that the patient has been doing physical therapy and using anti-inflammatories and has had activity modification, currently doing a home exercise program. It was recommended the patient undergo a lumbar transforaminal epidural steroid injection at bilateral sacral (S)1. It was stated that with the patient's last epidural injection, he had more than "5-0 percent (%) "reduction in pain and improved activities of daily living (ADLs). At issue is the medical necessity of pain management (injections).
The requested health service/treatment of pain management injections is not medically necessary for this patient. There is no documentation showing that the patient has severe radicular pain in a specific nerve root distribution. On exam, there was vague note of weakness at the bilateral foot dorsiflexors but this is not further quantified and it was stated that sensation was reduced in the feed but in no specific distribution. The patient previously underwent a lumbar epidural injection at bilateral L5 - S1 that "provided minimal relief." The provider states that the patient has been doing physical therapy but provides no duration of his treatment, states the patient has been using anti-inflammatories also with no duration of treatment and states that the patient has tried activity modification but again no specific duration of treatment and no medical records that corroborate this. Medical necessity is not established.