Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain

Treatment is a lumbar epidural steroid injection

The insurer denied coverage for a lumbar epidural steroid injection
 
The denial is upheld

The patient is a female who presented to her doctor for evaluation of lower back and right knee pain. Her pain is rated 6/10 and is worse with sleeping, walking prolonged periods, bending forward and backward and twisting. No associated numbness or tingling. She had minimal relief with a right knee steroid injection. A joint specialist recommended partial replacement. She has had NSAIDs (non-steroidal anti-inflammatory drugs), Celebrex, analgesic ointments, physical therapy, home exercise program and chiropractor. Her daily activities of living are affected. 

Her lumbar MRI (magnetic resonance imaging) shows at L (lumbar) 4-5 facet arthropathy, grade 1 anterolisthesis and disc bulge resulting in mild spinal canal and left greater than right foraminal stenosis. L5-S (sacral) 1 left greater than right facet arthropathy and mild disc bulge minimally encroaching on the spinal canal and neural foramina. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient per guidelines.

The epidural steroid injection is not medically necessary. Her complaints and exam are not consistent with imaging and the requested injection. She complains of mostly back pain and right knee pain that has been recommended she undergo a partial knee replacement. Her exam shows a right sacroiliac dysfunction. She has a positive straight leg raise on the right but without description of where her pain is. It does not appear, based on the records that she has right L5 distribution pain and has mostly axial back pain. Her MRI does not show any significant compressive findings on the right at L5.

NIA (National Imaging Associates) EPIDURAL INJECTIONS OR SELECTIVE NERVE BLOCKS (caudal, interlaminar, and transforaminal) (Injection of local anesthetics with corticosteroids)
 Pain causing functional disability or average pain levels of > 6 on a scale of 0 - 10 (Manchikanti, 2013, 2011; NASS, 2013, 2012; Summers, 2013); AND
 Diagnostic transforaminal injection to identify the pain generator for surgical planning 
(Manchikanti, 2013); OR
 Conservative therapy
 Acute pain or exacerbation of chronic radicular pain with the following clinical timeframes:
 Neck or back pain with acute radicular pain (Summers, 2013): 
 After 2 weeks or more of acute radicular pain that has failed to respond or poorly responded to conservative management unless the medical reason this conservative treatment cannot be done is clearly documented, (active components not required) (Manchikanti, 2013; Summers, 2013); OR
 Spinal stenosis (foraminal, central or disc disease) causing axial or radicular pain (Lee, 2009; Manchikanti, 2013):
 Patient must engage in some form of other active conservative treatment* for a minimum of 6 weeks in the last 6 months; OR details of engagement in other forms of active conservative non-operative treatment, if the patient had any prior spinal injections prior to epidural injections, unless the medical reason this conservative treatment cannot be done is clearly documented; (Manchikanti, 2013; Summers, 2013) (1)

CMS (Centers for Medicare & Medicaid Services) guidelines state that exclusions include:

ESIs (epidural steroid injection) to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, cervicogenic headaches are considered investigational and therefore are not considered medically reasonable and necessary. (2)

The insurer's denial of coverage for a low back pain management injection is upheld. Medical Necessity is not substantiated.