Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain.
Treatment: Additional Pain Injections.

The insurer denied the Additional Pain Injections.  The denial is overturned.

The patient is a female with low back pain.  At a visit, the patient was following up after a right L3-S1 (third lumbar spine vertebra to first sacral vertebra) radiofrequency ablation with low back and lower extremity pain. The pain was an eight out of ten (8/10).  The patient's past medical history is significant for history of breast cancer, Parkinson's, and fibromyalgia. Her pain medications include: Tylenol with codeine and lidocaine patch.  Her past history of injections include lumbar and cervical injections.  Within the last 12 months, the patient received a caudal epidural and four lumbar radiofrequency procedures (two left and two right at L3-S1 [(third lumbar spine vertebra to first sacral vertebra)]).  In an addendum, it is noted that the patient received more than 50% improvement with previous caudal epidural steroid injection (ESI) and repeat caudal epidural steroid injection (ESI) was requested.  Magnetic resonance image (MRI) of the lumbar spine from 08/30/2021 is significant for mild disc bulge, disc desiccation and severe right and moderate left foraminal stenosis at L5-S1 (fifth lumbar spine vertebra to first sacral vertebra).

The request for caudal epidural steroid injection was denied as it is noted the patient has been treated for approximately 12 months or has had more than four injection within the past 12 months.  In the appeal letter, it is noted that the patient had previous treatment "such as physical therapy with minimal relief for greater than 3 months, massage with minimal relief with greater than 3 months, and chiropractor treatment with minimal relief for greater than 3 months."  The patient had a previous caudal epidural with 90% reported pain relief and increase in function of unspecified duration.  An addendum was added stating patient received more than 80% relief for approximately more than eight months.

Yes, the proposed treatment is medically necessary.
As per the guidelines for Medical Necessity appeals:
 "You are requested to determine, whether the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. See specific medical necessity case questions on the template.
 You shall consider the:
- Clinical standards of the health plan (but are not bound by, the health plan's medical criteria (including e.g., definitions of medical necessity and cosmetic surgery),
- Information provided concerning the patient,
- Attending physician's recommendation, and
-  Applicable and generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations".

It generally would not be considered medically reasonable and necessary for treatment with epidural steroid injection (ESI) to extend beyond 12 months. Use beyond twelve months requires the following:  1) Pain is severe enough to cause a significant degree of functional disability or vocational disability (MET.), 2) Epidural steroid injection (ESI) provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline) (MET.), 3) Rationale for the continuation of epidural steroid injections (ESIs) including but not limited to patient is high-risk surgical candidates, the patient does not desire surgery, recurrence of pain in the same location relieved with epidural steroid injections (ESIs) for at least three months,(MET with addendum.), and he primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use. (Not applicable.)

To warrant medical necessity in continuing to repeat epidurals beyond 12 months or more than four per 12 months, the duration of relief must be significant (i.e., at least three months).  With the addendum stating the patient received more than 80% relief for more than eight months, this request now meets medical necessity.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.