Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and neck pain

Treatment: pain injection (62321 x 1)

The insurer denied coverage for pain injection (62321 x 1)

The denial is upheld.

 

This case involves an adult who was seen with a chief complaint of back pain, neck pain, and right hip pain.  The visit was conducted via telemedicine due to COVID-19.  Records claimed that the patient was involved in multiple motor vehicle accidents and previously received a lumbar (L) 4-5 interlaminar injection which reduced her pain from 10/10 down to 3/10.  The physician claimed that the patient received 80% (percent) pain relief lasting up until the time of her visit.  This allowed her to move around and sleep better.  Her current complaints included 8/10 neck pain with radiation to the bilateral upper extremities that extended down to her hands with numbness and tingling.  She also reported low back pain rated 6/10 going to the buttocks and radiating to both lower extremities down to the feet.  She was taking ibuprofen and cyclobenzaprine.  A reference was made to unofficial electrodiagnostic testing indicating evidence of chronic bilateral lumbar (L)5 radiculopathy.  There was a reference to unofficial electromyography of the upper extremities indicating evidence of chronic bilateral cervical (C) 6 radiculopathy.  There was a reference made to an unofficial magnetic resonance imaging (MRI) of the lumbar spine noting facet and ligamentous hypertrophy but no significant pathology.  An unofficial MRI of the cervical spine noted mild multilevel degenerative disc disease.  Unofficial lumbar x-rays noted degenerative changes.  X-rays of the cervical spine from the same date noted degenerative changes with straightening of the normal cervical lordosis, which may have indicated underlying spasms.  The examination indicated lumbar axial trigger points, decreased range of motion due to pain with positive straight leg raise testing at 30 degrees.  The patient had positive bilateral sacroiliac joint pathology with positive compression, distraction, Faber, Gaenslen's, thigh thrust.  Motor strength of both lower extremities was reportedly 445 for the extensor hallucis longus bilaterally and gastrocnemius bilaterally.  Reflexes were 2/4 at the patellas and 1/4 at the Achilles.  The patient reportedly had tenderness to the cervical facets bilaterally at C6-C7 and C7-thoracic (T) 1 with decreased range of motion due to pain and reduced strength to the right handgrip graded 4/5 in a C8 distribution and right intrinsics at T1.  Reflexes were 2/4 throughout except for the bilateral triceps at 1/4.

Current medical literature states that epidural steroid injections have been utilized for pain relief since 1952.  When indicated, they are an invaluable nonsurgical treatment for low-back pain radiating to the lower extremities and less commonly, for neck pain radiating to the arms.  Indications include a need to treat irritation and inflammation of spinal nerve roots.  The documentation provided for the review did not include the official imaging reports nor were there any in-office physical examinations.  All the assessments were conducted via telehealth and did not provide a true depiction of the extent of the patient's condition.  While records indicated the patient had complaints of neck pain, the evidence did not suggest that there was specific objective evidence of nerve root irritation or radiculopathy to justify the requested treatment.  As such, the denial of coverage for pain injection (62321 x 1) was appropriate.  

The pain injection (62321 x 1) was not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for pain injection (62321 x 1) is not substantiated.