Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approveC1-C2 medial branch blocks. We decided that the Plan does not have to pre-approveL5-S1 medial branch blocks. You asked the Plan to pre-approve medial branch blocks. You say that the requested C1-C2 and L5-S1 injections are medically necessary.The Plan says that the requested C1-C2 and L5-S1 injections do not meet criteria.We decided that the Plan has to pre-approveC1-C2 medial branch blocks. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.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 C1-C2 medial branch blocks. Our reviewer says that the requested C1-C2 injections meet criteria. Our physician reviewer found the enrollee is with a diagnosis of Spondylosis without myelopathy or radiculopathy, cervical region. He complained of neck pain. An MRI has demonstrated multi-level discogenic degenerative disease, most pronounced at C6-7. C1-2 medial branch blocks on the right have been recommended for diagnostic and therapeutic purposes.The documentation supports that the requested C1-2 injection meets the coverage criteria established by the LCD. The enrollee's symptoms started three years ago, and limit his daily activities. Home therapy exercises, chiropractic care, injections, activity modification, and NSAIDs have been tried and provided minimal relief.There are no upper extremity radicular symptoms reported. There is no documentation of non-facet pathology. The clinical assessment by the orthopedic surgeon implicates the right C1-2 joint as the source of the enrollee's pain.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of C1-C2 medial branch blocks have been met.Therefore, we decided that the Plan has to pre-approveC1-C2 medial branch blocks. We also decided that the Plan does not have to pre-approveL5-S1 medial branch blocks.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.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 L5-S1 medial branch blocks. Our reviewer says that the requested L5-S1 injection does not meet criteria. Our physician reviewer found the enrollee is with a diagnosis of Spondylosis without myelopathy or radiculopathy, cervical region. He complained of neck pain. An MRI has demonstrated multi-level discogenic degenerative disease, most pronounced at C6-7. In regards to the requested L5-S1 injections, there is no documentation that supports L5-S1 injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of L5-S1 medial branch blocks have not been met.Therefore, we decided that the Plan does not have to pre-approveL5-S1 medial branch blocks.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.