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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic interlaminar epidural injection and/or sacroiliac joint injection. With regard to the request for cervical epidural steroid injection, there is medical evidence supporting this treatment modality in specific patients. Medical literature noted that, repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. This patients records document chronic neck pain with a diagnosis of cervical radiculopathy and severe degeneration with a C5-6 and C6-7 disc herniation with stenosis. The provider notes that the patient is experiencing neck pain and bilateral upper extremity paresthesias. The patient underwent a prior cervical epidural steroid injection in October 2020 and reported 95% pain relief which lasted several months. In a progress report dated early of August of 2021, the provider noted that the patient experienced significantly reduced neck pain for over six months after the cervical epidural steroid injection. The neck pain and arm paresthesias have returned and are interfering with the patients ability to exercise. Previous treatment with physical therapy exacerbated the patients pain. The patients current medication regimen includes Naproxen and gabapentin. Given the documentation of failed physical therapy and significant relief with prior cervical epidural steroid injection lasting over six months, a repeat cervical epidural steroid injection is reasonable and supported by the medical literature. Therefore, the requested cervical/thoracic interlaminar epidural injection is medically necessary for treatment of this patient. However, there is a lack of data supporting the medical necessity of the of the requested sacroiliac joint injections in the management of this patients sacroiliac joint pain. Researchers reviewed the literature in order to establish an algorithm for treating patients with sacroiliac joint pain. The authors found that, Conventional non-surgical therapies such as medications, physical therapy, radiofrequency denervation, and direct sacroiliac joint injections may have some limited durability in therapeutic benefit. The authors concluded that it is generally accepted to start with conservative measures such as NSAIDs, muscle relaxants, and physical therapy. Within the documentation available for review, there is documentation of chronic low back pain with a diagnosis of sacroiliac dysfunction. In a progress report dated early of August of 2021, the provider notes that the patient underwent bilateral sacroiliac joint injection in December 2020, which provided significant relief for approximately five months. Within the last two weeks, the pain has returned to baseline and this pain has a major impact on the patients quality of life and activities. The patient has tried and failed physical therapy in the past which exacerbated the pain. The medical literature suggests procedures such as sacroiliac joint injections have poor evidence of efficacy but can be useful when multiple methods of treatment including conventional non-surgical therapies such as oral analgesic use, physical therapy, chiropractic treatment, and muscle relaxants are unsuccessful. Although there is documentation that the patient has failed treatment with physical therapy, there is a lack of documentation that the patient has exhausted the other conservative treatments recommended in the medical literature. Therefore, the requested sacroiliac joint injection is not medically necessary for treatment of this patient. All told, the requested cervical/thoracic interlaminar epidural injection is medically necessary for treatment of this patient, while the requested sacroiliac joint injection is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in pain medicine 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.