Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Pain Management (lumbar epidural steroid injection).
The health plan denied the requested pain management (lumbar epidural steroid injection).
The health plan's determination is upheld.

The patient is diagnosed with lumbar radiculopathy. 
A magnetic resonance imaging (MRI) of lumbar spine revealed (lumbar-sacral) L5 - S1, postoperative changes from a right L5 hemilaminotomy. There is disc bulge with superimposed central extrusion that results in mild spinal canal and left greater than right subarticular zone stenosis. There is encroachment on the traversing right S1 nerve and a compression of the traversing left S1 nerve root. There is mild bilateral foraminal stenosis.
A procedure report shows the patient underwent a lumbar epidural steroid injection at L5 - S1 interlaminar space.
A progress report shows the patient was seen regarding sacroiliitis at the right and left sacroiliac joint, status post sacroiliac (SI) joint intra-articular injections. The patient reported a pain level of 3/10. Medications included Bupropion and Sertraline. A physical examination was unremarkable. The plan was for a lumbar epidural steroid injection via caudal approach. There is a "note" at the bottom of this progress report stating that the patient has right-sided S-1 radicular pain and the patient would like to proceed with repeat injections. It was stated she had a critical straight leg raise on the right and lumbar spasm as well as bilateral posterior superior iliac spine (PSIS) tenderness, although this was not noted in the actual physical examination portion of the report. It was noted they will proceed with repeat epidural steroid injections. Home exercises were reviewed with the patient.

At issue is the medical necessity of the outpatient pain management procedure.

I uphold, in whole the health plan's determination of medical necessity.

No, the requested health service/treatment of the outpatient procedure (pain management) is not medically necessary for this patient. Per evidence based Official Disability Guidelines (ODG) guidelines, epidural steroid injections can be considered when there is evidence of radiculopathy on examination with neurological deficits in a specific dermatomal/myotomal distribution, corroborative findings on imaging studies or electrodiagnostic testing, failure of conservative treatment for at least six weeks to include exercise, physical therapy/chiropractic treatment, and appropriate medications such as nonsteroidal anti-inflammatories, muscle relaxants, and/or adjuvant neuropathic medications such as antidepressants or anticonvulsants. If after the initial block/blocks are given and found to produce pain relief of at least 50-70% pain relief for at least 6-8 weeks, additional blocks may be supported. Repeat injections should be based on continued objective documented pain relief, decreased need for pain medications, and functional response. In this case, the patient is noted to have a history of low back pain and prior to being recommended for a lumbar epidural injection had just undergone sacroiliac joint injections. The most recent progress note submitted does not include a physical examination and there is no objective evidence of radiculopathy on exams such as diminished motor strength, sensation, or reflexes and a specific distribution. The patient is also noted to be status post lumbar fusion in and the most recent magnetic resonance imaging (MRI) although it does show disc extrusion with nerve root compression, this MRI was performed prior to the lumbar fusion. The requested lumbar epidural steroid injection is not medically necessary.