Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injections (62321) for the enrollee.

You asked the Plan to pre-approve epidural steroid injections (62321). You say that this treatment is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for anterior cervical discectomy and fusion. Initially, the health plan determined that they were unable to approve Injection(s) of diagnostic or therapeutic substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic, with imaging guidance. The Maximus Physician Reviewer determined that the enrollee had uncontrolled pain and clear abnormal neurologic findings. The epidural was an attempt to avoid surgery and was determined to be medically appropriate. The Plan has requested a re-opening, stating that they presented the wrong information. The issue was whether cervical surgery was medically reasonable and necessary, rather than an epidural steroid injection.

Our Medical Director says that review of the medical record shows the enrollee is a 49-year-old woman with neck pain. An MRI performed for an indication of cervical radiculopathy showed focal left foraminal disc protrusion resulting in moderate/severe left C6 foraminal stenosis. The enrollee had an orthopedic surgery consult in the hospital for severe neck and left upper extremity pain for greater than one week. The enrollee had documented weakness, with 4+/5 left grip strength at that time, and she was diagnosed with cervical radiculopathy. The enrollee was taking oxycodone as needed for pain. The enrollee was evaluated for severe left sided neck pain which referred down the left shoulder to the arm. A cervical epidural steroid injection (ESI) was performed at the C6-7 level. The enrollee was re-evaluated. It was documented that the ESI improved the left upper extremity symptoms for only 6 hours. The enrollee had documented weakness, with 4/5 left grip strength. NSAIDs did not provide relief. The pain is reported to be too severe that the enrollee cannot tolerate physical therapy.

The Plan stated that they could not approve spine fusion surgery because they did not see failed non-surgical treatment for a 6-week period, spinal cord compression, foraminal stenosis, major new problems with strength, osteomalacia, or problems with prior surgery.

Our Medical Director has concluded that the controlling rule in this case is based upon the Social Security Act Section 1862(a)1(A) that defines when a service is medically necessary in the absence of a National or Local Coverage Decision. In this case, the enrollee has had unremitting radicular pain despite conservative treatment, with evidence of moderate to severe foraminal stenosis, and clear documentation of progressive weakness. This presentation is a medically reasonable and necessary indication for the surgical treatment of cervical radiculopathy. Therefore, medical necessity for the approval of this service has been established.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections (62321) have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injections (62321) for the enrollee.

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.