Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Facet Joint Injections
The insurer denied the facet joint injections.
The health plan's determination is upheld.

The patient is a female who is diagnosed with back pain. The records provided show that a request for facet joint injections was previously denied and upheld on appeal as not medically necessary noting that the records did not specify what levels of the spine would be treated and the patient did not have sufficient response to the prior injection with at least 75 percent (%) pain relief.

A magnetic resonance imaging (MRI) lumbar spine revealed previous left-sided laminectomy lumbar vertebrae (L)5 to sacral vertebrae (S)1. It also revealed moderate degenerative disc narrowing was again noted with mild left posterior lateral bony productive change and mild postsurgical scarring at the left anterolateral margin of the thecal sac and the mild left L5 and S1 root deformity was unchanged. The MRI also revealed mild posterior bulging disc annulus L4 to L5 with moderate facet arthropathy. There are mild to moderate posterior thecal sector deformities and right foraminal narrowing. The MRI also revealed that there is increasing degenerative disc narrowing and bony productive change with less significant soft disk. The overall degree of neural compression is unchanged. There is mild posterior bulging disc annulus L2 to L3 with moderate facet arthropathy and abundant posterior epidural fat. There is mild thecal sac compression which is mildly increased since the prior examination.

There is a procedure report that shows the patient underwent a "lumbar epidural steroid injection number (#)1" for the treatment of "lumbar radiculopathy." There is another procedure report that shows the patient underwent a "therapeutic" left-sided L4/L5 and L5/S1 medial branch block with a combination of Lidocaine 1% and 4 milligrams (mg) of Celestone for a total injected volume of 6 milliliter (mL). It was noted they would repeat the injection in two weeks. 

There is a "telephone encounter" stating that the patient has positive Kemps test, positive facet loading and a positive compression test of the left lumbar spine. She had 2 injections that blocked the facets at the left L4/L5 and L5/S1 with blocking 3 medial branch nerves 2 separate times with lidocaine and this gave her 80% pain relief rover 6 weeks. She now has increased pain and is in need of radiofrequency ablation of the medial branch nerve of the lumbar spine at these levels. She has continued in physical therapy and with her medications. The severe left non-radicular low back pain is affecting her activities of daily living.

The records indicate that the patient has a history of chronic back pain but it appears the patient also has a history of radiculopathy as the patient recently underwent a lumbar epidural steroid injection for the treatment of lumbar radiculopathy. The provider states that the patient underwent 2 diagnostic medial branch blocks with 80% pain relief for over 6 weeks. However, there are only two procedure reports provided for review, one of which was for the epidural steroid injection. 

The second procedure report notes that the patient underwent a "therapeutic" left-sided L4 to L5 and L5 to S1 medial branch block using a combination of Lidocaine and Celestone for a total volume of 6 mL. This is a therapeutic block, not a diagnostic block which would only use 0.5 mL or less of anesthetic only with no steroids. The MRI provided shows multiple significant findings with disc protrusions, left L5 and S1 root deformity and neural compression. The patient does not meet criteria to undergo lumbar radiofrequency ablation given that imaging studies suggest other obvious causes for the patient's pain and the patient has not undergone 2 true diagnostic medial branch blocks with a positive response.