Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 62-year-old male who presented to his provider on 4/16/21. The records noted recurrent and progressive low back pain, bilateral hip pain and leg pain associated with spinal stenosis. The patient has requested reimbursement for epidural injections performed on 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that with regard to the request for lumbar epidural steroid injections, there is medical evidence supporting this treatment modality in specific patients. Hooten and Cohen noted, aIn patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief.a Benyamin and colleagues concluded, aThe evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids.a In terms of treatment algorithms, Diwan and colleagues noted, aThe traditional treatment algorithm for lumbar spinal stenosis (LSS) consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered.a Regarding repeat epidural steroid injections, Murthy and colleagues stated, aRepeat transforaminal epidural steroid injection (TFESI) may be performed for recurrence of radicular pain with the expectation of recovery of most or all previously achieved benefit; acute pain patients will likely recover all prior benefit. Repeat TFESIs within three months of the index injection can provide cumulative benefit.a In this case, the patient was undergoing treatment for chronic low back pain, hip pain, and leg pain and was diagnosed with lumbosacral radiculitis and spinal stenosis of the lumbar region. There is documentation that the patient previously tried physical therapy which adid provide some improvementa and the patient continued performing the exercises, but it was not sufficient to control the pain. The patient subsequently underwent epidural steroid injections performed in January 2018 and October 2019, which provided significant relief (100% pain relief, which lasted about a year each) but the pain returned. Therefore, the patient underwent a repeat epidural steroid injection on 5/05/21. The medical literature supports treatment with an epidural steroid injection after failure of conservative treatment, which includes physical therapy, medication, education, and exercise. Furthermore, repeat epidural injections are supported when there is recurrence of radicular pain. However, in this patientas case, there is a lack of documentation of recent failure of conservative treatment prior to the lumbar epidural steroid injection performed on 5/05/21. There is a lack of support for the services at issue in this setting. Therefore, epidural injections performed on 5/05/21 were not medically necessary for the treatment of this patient.