Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain with radiation to the right lower extremity
Treatment: Pain injections (64483 X1) (64484 X 1)
The insurer denied coverage for pain injections (64483 X1) (64484 X 1).
The denial is overturned.

The patient is a male seen by Orthopedic Surgery due to reports of 10 days of back pain with radiation to the right lower extremity. He takes over the counter pain medication. He endorses neurogenic claudication. His exam notes a positive straight leg raise. He was prescribed physical therapy, Medrol dosepak and a referral to Pain Management. He was seen by a physical medicine and rehabilitation (PM&R) specialist for initial visit of back pain with radiation into the posterior lateral thigh, lateral calf, dorsum of foot associated with numbness and tingling. He is unable to sleep. He had a Medrol dosepack with moderate relief and was re-prescribed Medrol dosepak without relief. He is unable to participate in formal physical therapy due to pain. His work performance is limited. He is taking gabapentin. His exam notes a positive straight leg raise on the right. The plan was for a lumbar magnetic resonance imaging (MRI). The lumbar MRI states a right central and lateral recess protrusion with impingement of the thecal sac and descending right Lumbar (L) 5 nerve root with extruded disc fragment within the right lateral recess at L4-5. He was then seen by PM&R, who stated that the patient returned to go over his lumbar MRI. He reports lumbar back pain with radiation to the right lower extremity. His MRI shows at L4-5 a right central and lateral recess protrusion, with impingement of the thecal sac and descending right L5 nerve root. There is inferior migration of an extruded disc fragment within the right lateral recess. He was prescribed Neurontin 100 milligrams (mg) four times a day, Toradol 10 mg and prednisone 20 mg. His exam is positive for a straight leg raise and significantly reduced lumbar range of motion. The plan states that his severe pain is not responding to medications like non-steroidal anti-inflammatory drugs (NSAIDs), Toradol and oral steroids. He is unable to tolerate physical therapy. They would schedule him for a right L4 and L5 injection to facilitate pain control and physical therapy. He would be referred to a spine surgeon if the injection did not help significantly. 

The records clearly show that he has been managed on two rounds of oral steroids, Toradol, over the counter pain medication, and gabapentin for at least six weeks and it is documented that his pain is severe and does not allow formal physical therapy sessions. The physician's plan specifically states that the injections are in an attempt to reduce pain so that he can perform physical therapy. According to National Imaging Association (NIA) and nationally accepted Centers for Medicaid and Medicare Services (CMS) guidelines, he meets criteria. 

He has failed oral medications that include 2 rounds of oral steroids, Toradol, gabapentin, and over the counter pain relief. His MRI shows nerve root compression at L5. It is documented in the medical record that he is unable to participate in therapy due to severe pain. He is functionally limited. The injections are medically necessary to allow for some pain relief in an attempt to pursue therapy. If the injections fail, he will be referred to a surgeon. The request meets NIA guidelines and standard of care.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for pain injections (64483 X1) (64484 X 1) is overturned. Medical necessity is substantiated.