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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck spine with dye and epidural injection for evaluation and treatment of the enrollees neck and low back pain. Findings:  The physician reviewer found that In general, cervical spine MRIs are recommended due to the emergence of a red flag, physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology. In this case, the patient presents with worsening neck pain radiating down his arms with associated numbness and tingling. Clinical examination findings evidence reflex changes. There is evidence of six weeks of failed conservative treatment. An epidural steroid injection is under consideration and the provider has requested updated imaging. Based on the clinical documentation submitted for review, the requested cervical spine MRI is supported as medically necessary. Therefore, the request for MRI of the neck with dye has been established as medically necessary for evaluation of the patients medical condition. However, the medical literature does not recommend cervical epidural steroid injections given the serious risks of this procedure in the cervical region and the lack of quality evidence for sustained benefit. A review by Benzon and colleagues suggested that epidural steroid injections are not recommended higher than the C6-7 level; no cervical interlaminar epidural steroid injections should be undertaken at any segmental level without pre-procedural review; and particulate steroids should not be used in therapeutic cervical transforaminal injections. In addition, Cohen and colleagues conducted a multicenter, randomized, comparative-effectiveness study comparing epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain. For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed. At this time, there is a lack of evidence based medical literature supporting the proposed cervical epidural steroid injection. Additionally, the request does not include the level(s) to be injected. For the reasons provided, the request for epidural injection is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.