Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested The patient has requested authorization and coverage for bilateral intraarticular facet joint injections at L4-L5 and L5-S1 (CPT 64493 and 64494). Chou and colleagues note that despite debate regarding the appropriate use of therapeutic modalities in managing lumbar facet joint pain, the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. In a study of the effectiveness of lumbar facet joint blocks, Cohen and colleagues report facet blocks are not therapeutic and that higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. Manchikanti and colleagues conclude that based on the present assessment for the management of spinal facet joint pain, there is Level II evidence for long-term improvement for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. Kwak and colleagues report that intraarticular lumbar facet joint corticosteroid injection treatment may be effective, regardless of facet joint osteoarthritis severity. The authors note that while intraarticular lumbar facet joint corticosteroid injections may be a useful clinical option for the management of facet joint osteoarthritis mediated low back pain, the present study was limited by its retrospective design and relatively small sample size, and that further studies are required on the long-term effects of intraarticular lumbar facet joint corticosteroid injection. In this case, the patient is being treated for a longstanding history of axial low back pain that had worsened. An examination noted decreased flexion and extension, limited by pain, tight hamstrings bilaterally, and intact strength and sensation are intact. Facet mediated pain was not evident on this examination. Magnetic resonance imaging (MRI) reported mild facet arthropathy and ligamentum flavum thickening with mild left neural foraminal narrowing, without significant spinal canal or neural foraminal narrowing at L4-L5, and mild facet arthropathy, without significant neural foraminal or spinal canal narrowing at L5-S1. While the patient was seen via telehealth, and again, the notes from these visits reported that examination was either limited due to telehealth or was not performed. There remains no obvious current physical examination that supports facet mediated pain. The first examination noted appears to be the last full examination, and that examination also did not support facet-mediated pain. The patient reported relief from bilateral L4-5 and L5-S1 intraarticular facet injections on for four days until falling. However, given the lack of examination data to support facet-mediated pain and the limited support in current medical literature for the use of therapeutic facet injections as an effective and/or safe treatment for the noted pathology, the requested services are not medically indicated. Therefore, bilateral intraarticular facet joint injections at L4-L5 and L5-S1 (CPT 64493 and 64494) are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.