Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Lower Back Pain.

Treatment: current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The insurer denied coverage for current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code 9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59.

The denial is upheld.

This gentleman has chronic low back pain which radiates to his leg.  He has tried PT (physical therapy) and NSAIDs (non-steroidal anti-inflammatory drugs) without significant relief. 

The MRI (Magnetic Resonance Imaging) shows no disc Herniation, canal stenosis, or neuroforminal narrowing.  The EMG/ NCV (electromyography/nerve conduction velocity) shows L (lumbar)5-S (sacral)1 radiculopathy.

A provocative discogram performed showed L3-L4 concordant pain.  But another discogram performed showed L4-L5 non-concordant pain.  Of note, the physical exam states that he had pain while sitting. 

Despite multiple publications in the lumbar spine, value and validity of discography
continues to be debated (1). 

A systematic review of discography concluded: "This systematic review illustrates that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain." These criteria include pressure limits.  No pressures were recorded in either procedure notes.

Cueller et al (3) studied the impact of discography on the natural history of disc disease:
of the 150 subjects enrolled, 71 discography subjects and 72 control subjects completed the baseline evaluation. At 10-year follow-up, 57 discography and 53 control subjects completed all interval surveillance evaluations. There were 16 lumbar surgeries in the discography group, compared with four in the control group. Medical visits, CT/MRI [computed tomography/magnetic resonance imaging] examinations, work loss, and prolonged back pain episodes were all more frequent in the discography group compared with control subjects. 

The disc puncture and pressurized injection performed during provocative discography can increase the risk of clinical disc problems in exposed patients. 

In this patient, there have been two separate discograms performed.  No pressure readings are noted in either report.  The results, 9 months apart, are very different.  The MRI does not demonstrate any pathology.  

This procedure was not more likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of current procedural terminology (CPT) code 62290 x4 [injection procedure for diskography, each level; lumbar], Healthcare Common Procedure Coding System (HCPS) code S0077 [injection, clindamycin phosphate 300 milligrams (mg)], HCPCS code Q9966 [low osmolar contrast material, 200-299 milligrams/milliliter (mg/ml) iodine concentration, per ml], CPT code 72295 x 4 [discography, lumbar, radiological supervision and interpretation]- modifier 59 [Distinct Procedural Service] and CPT code 77003 [fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)]- modifier 59 should be upheld.  It is not more beneficial than any other standard treatments.