Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for facet joint injection of the lumbar and lumbosacral spine, and hydrocodone-acetaminophen (Norco). Findings: A medical study reported the safety and efficacy of therapeutic medial branch blocks in the treatment of low back pain. The study concluded that the findings establishes that facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. These findings are consistent with an earlier study, which concluded that, the evidence for lumbar facet joint nerve blocks using local anesthetics with or without steroid for managing chronic low back pain of facet joint origin is fair to good for short- and long-term improvement. Currently, the best evidence for the use of medial branch blocks is for diagnostic purposes prior to a radiofrequency ablation procedure. Other guidelines noted that, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Other guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Other findings opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has chronic low back pain with diagnosis of lumbar spondylosis and confirmation of lumbar facet disease on x-ray. The patient is reportedly involved in physical therapy and a home exercise program, which have been beneficial. The patient underwent therapeutic lumbar facet joint blocks. However, there is no documentation of the level of benefit or the duration of improvement with this intervention. The current evidence-based literature does not recommend therapeutic facet joint blocks due to weaker level of evidence compared to lumbar medial branch blocks in preparation for a radiofrequency ablation procedure. The providers notes do not include a current recommendation Norco for treatment of the patients low back pain. Moreover, there is a lack of documentation that the patient has failed nonopioid and other conservative therapies. The records report that treatment with physical therapy and a home exercise program has been beneficial. Based on the available medical records for review, national guidelines and literature reviews, the requested facet joint injection of the lumbar and lumbosacral spine, and hydrocodone-acetaminophen (Norco), are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services and medication are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.