Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve injections at level L5-S1. We decided that the Plan does not have to pre-approve injections at level L3-L4. You asked the Plan to pre-approve lumbar injections. You say that the enrollee's pain level was a 9 out of 10The Plan says that the enrollee's pain is not predominantly axial, and did not have at least3 months of pain relief from previous injections We decided that the Plan has to pre-approve injections at level L5-S1. The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve injections at level L5-S1. Our physician reviewer found that the enrollee has chronic neck and low back pain. His low back pain described as radiating down his left leg. The notes refer to a prior spinal fusion but do not specify what levels were involved. His motor functions are intact. He had physical therapy directed at his neck last year. There is no physical therapy documentation about his lumbar spine. It is also noted that he has tried chiropractic and traction. His MRI reveals only minimal changes at the L5-S1 disc. He had provocative discography and he had concordant pain only at L5-S1 disc. He is currently taking oxycodone, baclofen and Ibuprofen for pain. The concordant response at L5-S1 discography along with his pain description suggests L5-S1 disc pathology and a single transforaminal level is indicated. There is no indication for a separate anesthesia provider for sedation as this may interfere with the proper interpretation of the block. Only a single level transforaminal epidural steroid injectionis medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections at level L5-S1 have been met.Therefore, we decided that the Plan has to pre-approve injections at level L5-S1. We also decided that the Plan does not have to pre-approve injections at level L3-L4.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve injections at level L3-L4. Our physician reviewer found that the enrollee had selective nerve root injections at L3 and L4 which did not improve his pain. There is no indication for transforaminal epidural steroid injections at levels where the selective nerve root blocks were negative.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections at level L3-L4 have not been met.Therefore, we decided that the Plan does not have to pre-approve injections at level L3-L4.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.