Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain injections (facet joint injections)
The insurer denied Pain injections (facet joint injections).
The determination is upheld.

This is a patient who was diagnosed with back pain; spondylolisthesis, lumbar region; myalgia, other site. Magnetic resonance imaging (MRI) of the lumbar spine revealed moderate degenerative disc disease (lumbar ) L4 - L5 and L5 - sacral (S)1; small right-sided L4 - L5 herniation without compromise of the L5 nerve root in the recess or foraman; L5 - S1 broad-based bulging annulus with defects in the right and left pars interarticularis contributing to bilateral spondylosis with no evidence of extruded disc material or severe stenosis; large solid mass most related most probably to a large uterine fibroid.
The patient was seen for follow-up visit with complaints of chronic back pain and presented for MRI review. The patient tried physical therapy and the pain was too strong. She felt better but for a short period of time and now is having the worst pain in the low back. The pain has been present for over 7 years and is currently rated at 10/10. At issue is the medical necessity of pain injections (facet joint injections).

The requested health service/treatment of pain injections (facet joint injections) is not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, facet injections/medial branch blocks can be considered when there is objective examination findings consistent with facet mediated pain, absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure, as well as failure of at least 3 months of conservative treatment including physical therapy or chiropractic treatment, home exercise, and medications such as nonsteroidal anti-inflammatory drugs. If a diagnostic medial branch block is performed, this should be performed at no more than two joint levels. There should be no history of prior fusion at the levels to be performed and imaging studies should rule out other obvious causes for the pain (such as fracture, tumor, infection, or significant extraspinal lesion). Medial branch blocks should only be performed when radiofrequency facet neurolysis is being considered. The patient is noted to have complaints of chronic back pain and it was reported the patient is not able to complete physical therapy due to increased pain. The patient reportedly tried Tylenol, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin without relief. The policy notes that imaging studies cannot suggest other obvious causes for the pain (e.g., disc herniation, radiculitis, discogenic or sacroiliac pain). In this case, imaging studies revealed moderate degenerative disc disease L4 - L5 and L5 - S-1 as well as a right-sided disc herniation at L4- L5 and L5-S1 broad-based bulging annulus with defects in the right and left pars interarticularis contributing to bilateral spondylosis. There were no findings that suggest the facet joints are currently a pain generator. Medical necessity is not established.