Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 62-year-old female who has a long history of back pain. She indicates she benefited from an epidural injection she received in 2003. The patient has tried and failed physical therapy and pain medications. She has requested authorization and coverage for another epidural injection. The Health Plan has denied this request indicating the requested injection is considered experimental and not a covered benefit.The use of epidural steroid injections has been addressed in a recent guidelines statement by the American Society of Interventional Pain Physicians with a determination of moderate evidence of short-term relief for interventional injections. The patient has completed her non-operative treatment program without change in symptoms. An epidural injection was helpful in the past and is medically appropriate and reasonable in this situation. Accordingly, I have determined that the requested injection is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 62-year-old woman with back pain. She received an epidural injection in the past with excellent results. She has now requested authorization for a second injection. The Health Plan has denied the patients request on the basis the requested injection is considered experimental in this clinical setting.Epidural injections to alleviate lumbar and radicular pain are not experimental or investigational. They have been utilized for over 20 years and have a proven track record of providing pain relief. Many physicians prefer the epidurals in a series of three, staged over several months. There is very little risk and the potential for great benefit as exemplified by the patients experience with the first injection. Therefore, I have determined that the requested injection is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 62-year-old female with low back pain and radiculopathy due to degenerative disc disease and spinal stenosis. The patient experienced significant relief from an epidural injection she received in 2003. She now wishes to receive another epidural injection. The Health Plan has denied coverage for the epidural injection indicating it is not likely to be effective for this patients condition.Review of the medical literature shows there are multiple class I studies demonstrating the long-term efficacy of fluoro-guided transforaminal epidural steroid injections for low back pain and radiculopathy due to herniated discs, disc disease, and/or spinal stenosis. There is documented evidence the patient has benefited from her previous epidural injection; she is likely to again experience relief from a repeat injection. Therefore, I have determined that the requested injection is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.