Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Facet Neurotomy
The insurer denied facet neurotomy.
The determination is upheld.

The patient was diagnosed with back pain. Records indicate that the patient was recommended to undergo bilateral lumbar (L) 4-L5 radiofrequency ablation, which was denied by the health plan as there was no documentation showing the patient had two positive diagnostic medial branch blocks at the level being treated on two separate days, both showing at least 75 percent (%) pain relief.

A progress report notes that the patient seen for a follow-up visit with a chief complaint of low back and neck pain. The low back pain was rated at 6/10 and radiates to the bilateral buttocks, thighs, legs, and ankles and extends down to the feet. The patient reported numbness and tingling in the bilateral feet. Prior treatment included a physician directed home exercise program for greater than 6 weeks. The patient is not on any medications for pain. Physical examination revealed tenderness to palpation, tenderness at the left L3-L4 and L4-L5 facet joints and right L3-L4, L4-L5 and L5-S (sacral) 1 facet joints. Range of motion was limited. Straight leg raise was positive at 50 degrees (). There was decreased motor strength in the left L3, bilateral L4, left L5, and left S1 distribution. The plan was to continue Tylenol and ibuprofen as needed for pain, the patient was recommended for a lumbar support brace, and he was recommended to undergo bilateral L4-L5 and L5-S1 radiofrequency ablation. The provider states that the patient had bilateral L4-L5 medial branch blocks with 100% pain relief lasting for the duration of anesthetic used and better ability to bend, get dressed, get in and out of a vehicle and perform activities of daily living with less pain. The patient was also recommended for a formal course of chiropractic/massage/physiotherapy treatment for the lumbar spine and follow-up in four weeks. At issue is the medical necessity of facet neurotomy.

The requested health service/treatment of facet neurotomy is not medically necessary for this patient.

According to evidence-based Official Disability Guidelines (ODG), radiofrequency ablation can be considered when there are objective examination findings consistent with facet mediated pain, failure of at least 4 to 6 weeks of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. There needs to be documentation that a diagnostic medial branch block was performed [no intravenous (IV) sedation, local anesthetic only, no steroids, no more than 0.5 milliliters (mL) of injectate, and performed at no more than two joint levels] with a positive response to include at least 70% pain relief concordant with the duration of local anesthetic used. In this case, the patient has not failed an appropriate course of conservative treatment as it appears the patient has only done home exercises and only had a couple of sessions of physical therapy. The patient was also being recommended to undergo a course of formal chiropractic/massage/physiotherapy with no indication that they were completed. The patient is noted to have radicular complaints with back pain radiating into the bilateral buttocks, thighs, legs, ankles and extending down to the feet with numbness and tingling in the bilateral feet and neurological deficits on exam including diminished motor strength in the L3, L4, L5, and S1 distribution as well as a positive straight leg raise at 50. Radiculopathy is exclusionary criterion for facet procedures. The provider states the patient underwent a medial branch block with positive results, but this procedure report was not submitted for review and there was no pain diary submitted documenting the patient's response. The requested radiofrequency ablation is not medically necessary.