Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: Pain injections 
The insurer denied the pain injections. 
The denial is upheld. 

The patient is a female diagnosed with neck pain. Records show that a request for cervical epidural steroid injections was denied by the insurance carrier as the records did not show that the patient would have the injections under fluoroscopy, did not show that the patient's pain was severe from a slipped disc at a specific level or narrowing of the spinal canal confirmed by physical exam and image he and records did not show that the patient had tried and failed all conservative therapies to relieve pain before resorting to injections including at least six weeks of therapy or prescribed home exercise program and at least six weeks of activity modification.

Magnetic resonance imaging (MRI) of the cervical spine revealed postop changes compatible with anterior spinal fusion extending from cervical (C)3-C7.

Indicated in the progress note, the patient had complaints of neck pain radiating into the left shoulder down to the thumb and along the radial aspect of the arm rated at 8/10. The patient complained of functional limitations. Cervical exam revealed tenderness to palpation at the paravertebral muscles, limited range of motion secondary to pain. Motor strength, sensation, and reflexes were normal. Positive facet loading bilaterally. The plan was to continue with medications and the patient was recommended for a cervical transforaminal epidural steroid injection.

According to the progress note, the patient was seen for a follow-up visit with complaints of neck pain and headache rated at 8/10. It was reported she has excellent, greater than 50% (percent) analgesia with her current treatment regimen and states her pain level is 10/10 without treatment. She also complained of joint pain, muscle spasm, loss of function of affected area and headaches. Quality of life has remained the same. She is taking her medications as prescribed. She has functional limitations secondary to pain. Current medications include Linzess, Botox, Dilaudid, and is prescribed multiple medications from other providers. Past medical history was significant for hypertension and hypercholesterolemia as well as anxiety disorder. Physical examination of the cervical spine revealed her vertebral muscle tenderness bilaterally, limited range of motion secondary to pain. No motor or sensory deficits in the upper extremities and reflexes were equal and symmetric. There was positive facet loading bilaterally. Botox injection was performed. The provider states they provided the patient with a prescription for physical therapy program, and it was noted the patient would follow-up in four weeks, noting they would consider cervical epidural steroid injection or cervical facet joint injections. The subject under review is the medical necessity for requested pain injections.

The requested treatment of pain injections is not medically necessary for this patient. Records indicate the patient has complaints of neck pain. However, there are no objective findings of radiculopathy. Motor strength, sensation, and reflexes were normal in the upper extremities. There was no evidence of disc herniation, nerve root impingement or significant stenosis on MRI. Additionally, the patient has not failed an appropriate course of conservative management for the cervical spine to include at least six weeks of physical therapy or chiropractic combined with complaints with the daily home exercise program. The requested injections are not medically necessary.