Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Pain Management - facet joint injections (64493 x 1, 64494 x 1)
The health plan denied the Pain Management - facet joint injections (64493 x 1, 64494 x 1).
The health plan's determination is upheld.

This patient is diagnosed with low back pain. The patient is noted to have a history of chronic back pain and reportedly has failed conservative treatment. 
According to a progress report, the patient was seen for a follow-up visit regarding chronic back pain that radiates down the bilateral hips and legs, rated at 10/10. He reports pain has been getting progressively worse and localized across the low back with radiation down the left leg and the ankle and mild pain down into the right calf. He has numbness and tingling in the right leg. It was reported he had a magnetic resonance imaging (MRI) of his back showing a pinched nerve at (lumbar) L4 - L5. He is currently doing physical therapy with limited benefit. He has tried Tylenol, Motrin, Tramadol and Gabapentin without benefit. He was recommended to have a left L4, L5, (sacral) S1 medial branch block followed by a radiofrequency ablation but this has been denied by the insurance carrier. Physical examination revealed sensorimotor grossly intact in both lower extremities. There is severe facet tenderness at the lower lumbar spine at L3 - L4, L4 - L5 and (lumbar-sacral) L5 - S1 bilaterally. Severe sacroiliac (SI) joint tenderness is noted bilaterally with positive Patrick's bilaterally and positive pelvic compression test bilaterally. Straight leg raise was positive in both lower extremities at 40 and severe tenderness along the greater trochanters on both sides. Range of motion was limited. There was reference to an MRI of lumbar spine showing central disc herniation and spinal stenosis at L4 - L5 level in addition to facet arthrosis. The plan is to schedule the patient for diagnostic lumbar facet injections at bilateral L4 - L5 and L5 - S1.

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

The requested health service/treatment of Pain Management - facet joint injections are not medically necessary for this patient.
According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, facet injections/medial branch blocks can be considered when there is objective examination findings consistent with facet mediated pain, absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. If a diagnostic medial branch block is performed, this should be performed at no more than two joint levels. There should be no history of prior fusion at the levels to be performed and imaging studies should rule out other obvious causes for the pain (such as fracture, tumor, infection, or significant extraspinal lesion). Records provided indicate the patient has complaints of chronic back pain radiating down the bilateral lower extremities into the hips and legs, with the left side pain going down into the ankle as well as pain into the right calf with associated numbness and tingling in the right leg. On examination there was positive straight leg raise testing bilaterally at 40 and an MRI shows central disc herniation and spinal stenosis at L4 - L5 level. These findings are consistent with radiculopathy which is exclusionary criterion for facet procedures. The requested injections are not medically necessary.