Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Epidural Injections (Codes 64483x1 and 64484x1)
The insurer denied the epidural injections.
The denial has been upheld. 

This patient is a male diagnosed with back pain. 

The patient's magnetic resonance image (MRI) of the lumbar spine from 8 months ago revealed mild to moderate L (lumbar) 2-S (sacral) 1 disc bulges. There was no definite neural compression, spinal stenosis, or focal left-sided abnormality.

Early this year, the patient was seen for a follow-up visit with low back pain and radiculopathy reporting that the pain starts in the middle of the low back and radiates to the left buttock, wraps around the left hip and into the anterior, medial left lower extremity down to the great toe on the left. The patient has been having more episodes of numbness and tingling with pain and weakness in the left lower extremity with the leg giving away with a recent fall on a hunting trip with his son. The patient was seen previously by his chiropractor and also had a consultation with pain management, however he feels that the pain radiates down the leg from the low back is more bothersome than the pain in the sacroiliac (SI) joint. It was reported the patient has been doing at home exercises for lumbar spondylosis since his last visit at least five weeks ago. He has been taking approximately 2000 milligrams (mg) of Tylenol a day. Current medications were listed as acetaminophen, cyclobenzaprine, hydrochlorothiazide, Lisinopril, Metformin, naproxen, and pravastatin. On physical examination, motor strength was decreased in the bilateral lower extremities. There was diffuse tenderness to palpation. Range of motion was limited with pain and guarding. Sensory exam was decreased in the left lower extremity, normal on the right. Straight leg raise testing was negative for back or leg pain on the right, positive or pain into the left leg at ten degrees on the left. Imaging studies were referenced. It was recommended the patient undergo a left L3-L4 and L4-L5 transforaminal epidural steroid injection. The patient would follow-up in four weeks.

The letter of appeal notes that the request is for a left L3-L4 and L4-L5 transforaminal epidural steroid injection (two levels unilateral). It was stated that the patient has been doing home exercises, taking Tylenol, Flexeril, naproxen and Mobic since then. The provider states the MRI shows disc bulges at all levels from L2-L3 but increased disk space narrowing at L3-L4. The provider is requesting reconsideration for approval of the procedure.

Records provided indicate the patient with complaints of back pain radiating into the bilateral lower extremities, though this is not identified in a specific distribution. There is no documentation of disc herniation in a defined nerve root level or spinal stenosis confirmed by physical exam and imaging. The MRI notes that there is no definite neural compression, spinal stenosis, or focal left-sided abnormality. There is also no documented failure to respond to conservative therapy including at least six weeks of chiropractic, physical therapy or prescribed home exercise program or at least six weeks of activity modification. It was vaguely noted the patient has had intermittent chiropractic treatment in the past, but no indication of at least six weeks of this type of therapy. There were also copies of home exercises but no indication that the patient was compliant with ongoing performance of these exercises for at least six weeks for the current episode of pain. The requested injection is not medically necessary.