Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Epidural Caudal Injection.
The insurer denied the epidural caudal injection.
The health plan's determination is upheld.

The patient is a male with a diagnosis of low back pain. Records show that a request for lumbar epidural steroid injection was denied by the insurance carrier as there was no documentation that the patient had participated in a program to manage pain including therapy, medication, education, mental and social support.

The magnetic resonance imaging (MRI) of lumbar spine revealed that the patient was status post laminectomy and fusion at lumbar vertebrae (L)4-L5 with expected postoperative changes. There is also moderate central spinal canal stenosis and moderate to severe bilateral neural foraminal narrowing at L2-L3 secondary to broad-based concentric disc bulge and facet arthropathy. There is also moderate central spinal canal stenosis and severe right lateral recess stenosis at L3-L4 secondary to broad-based right eccentric disc bulge.

The patient was seen for a follow-up visit regarding his chronic back pain radiating to the right buttock, left buttock, right hip, left hip, right thigh, left thigh, right knee, right calf, right ankle, right big toe and right 5th toe. It was noted that the patient previously underwent a right lumbar transforaminal epidural injection at L4-L5 and L5-sacral vertebrae (S)1 reporting only 10 percent (%) relief. Gabapentin and Tizanidine help with the pain. The patient has tried physical therapy completing two months targeting the low back and was not effective. The patient is having an acute exacerbation of a chronic condition. The patient does a home exercise program targeting the low back 5 times per week. The patient also had a nerve block targeting the L4-L5 and L5-S1 levels with only 10% relief. The physical examination revealed limited painful lumbar range of motion. The patient's lower extremity motor strength was 5 out of 5 bilaterally. The Flip test was positive, and he had a positive facet challenge and positive Faber. The patient's sensation was intact in the lower extremities. The patient was given medication refills and was recommended to undergo a caudal epidural steroid injection.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of the epidural caudal injection is not medically necessary for this patient. There were no objective findings of radiculopathy on examinations such as decreased motor strength, sensation, or reflexes in a specific distribution or positive straight leg raise testing. Additionally, the patient has previously undergone 2 different lumbar epidural steroid injections, both resulting in only 10% relief and the patient does not meet criteria for a repeat injection. Additionally, the patient was noted to be having an acute flareup but had not recently participated in physical therapy and does not appear to have failed appropriate conservative management to address the flareup prior to consideration for injection therapy. Medical necessity is not established.

The health plans determination of medical necessity is upheld in whole.