Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute on Chronic Low Back Pain

Treatment: Pain Injection: (64493 x 1, 64494 x 1, 64495 x 1)

The insurer denied coverage for Pain Injection: (64493 x 1, 64494 x 1, 64495 x 1)

The denial is upheld 
                                               
According to the documentation submitted, this is the case of a patient with a history of acute on chronic low back pain. An initial request for a magnetic resonance imaging (MRI) by the patient's primary care provider (PCP) was denied after only 6 weeks of conservative treatment. The patient was then referred to another provider for further evaluation and treatment. The other provider noted pain had been present for more than 3 months, that the patient had tried and failed all conservative measures, and the patient's pain was significantly affecting all aspects of their activities of daily living (ADL's) including self-care. The other provider's differential diagnosis included lumbar facet arthropathy, lumbar radiculopathy, osteoarthritis (OA), tendinitis, neuropathy, sacroiliitis, internal disc disruption (IDD), lumbar strain, right hip pain, right hip osteoarthritis. No additional requests for imaging were made by the other provider. The physician recommended right L (lumbar) 3, L4, L5 lumbar medial branch blocks (LMBB) for pain control. The insurer has denied coverage for (64493 x 1, 64494 x 1, 64495 x 1). 

Facet joint interventions generally consist of four types of procedures: intraarticular (IA) facet joint injections, medial branch blocks (MBB), radiofrequency ablations (RFA), and facet cyst rupture/aspiration. Centers for Medicare and Medicaid Services (CMS) guidelines (Facet Joint Interventions for Pain Management L38803) indicate that facet joint interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 1) Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale, 2) Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative management (as tolerated), 3) Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst), 4) There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity (1).

Based on the documentation provided, this patient does meet the CMS recommended criteria for diagnostic or therapeutic LMBBs. However, according to UpToDate (2) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) consensus practice guidelines (3), patients with persistent symptoms beyond 12 weeks should have imaging to rule out other sources of pain prior to any invasive treatment. While imaging may not have been reasonable or necessary in the acute phase of this patient's lumbar back pain, it would be reasonable and necessary after 3 months of persistent pain. Appeal notes state that the "carrier denied the MRI of lumbar spine request from the patient's PCP and refused to accept the request from our group", however, only the PCP MRI request is documented in the records provided. There is no documentation provided to indicate any new imaging requests were made by the other provider prior to proceeding with LMBBs. Despite prior reasonable MRI denial, imaging would aid in the management of this patient's back pain prior to performing LMBBs. The denial should be upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Pain Injection: (64493 x 1, 64494 x 1, 64495 x 1) is not substantiated.