Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a patient who was diagnosed with low back pain, lumbar degenerative disc disease, lumbosacral intervertebral disc disease, and chronic lumbar radiculopathy.
A letter of denial notes that on appeal the denial for a second facet injection was upheld as not medically necessary as records did not show that the first diagnostic block produced 80% (percent) or greater relief of pain and duration of relief consistent with the agent employed as well as records did not show at least two weeks had passed since the first injection.
There is a letter of appeal stating that regarding the denial of number (#) 2 lumbar diagnostic facet injections, the injections were denied as they did not show at least two weeks had passed since the first injection. They requested a reconsideration/appeal.
Magnetic resonance imaging (MRI) of the lumbar spine revealed moderate lumbar (L) 4-L5 central canal stenosis with diffuse disc bulge complex and facet arthropathy with severe lateral recess narrowing and moderate to severe bilateral foraminal stenosis; L5-sacral (S) 1 diffuse disc bulge and osteophyte complex with superimposed small left lateral recess disc protrusion, mild central canal narrowing, left lateral recess narrowing, and severe left and moderate to severe right foraminal stenosis; L3-L4 mild central canal stenosis with dorsal disc bulge and osteophyte complex and moderate bilateral foraminal narrowing; L2-L3 dorsal disc bulge and osteophyte complex with mild bilateral foraminal narrowing.
The patient was seen with complaints of low back pain and noted that her primary care physician (or provider) (PCP) took her off of Meloxicam due to "kidney issues" but was told it wasn't that bad and was not given any alternative. She complained of muscle pain in the low back. She reports that the previous injection did help with her radicular symptoms and she is not having shooting pain down the left leg anymore and now the pain is just axial across her back. On physical examination, there was tenderness to palpation at the left paraspinal and right paraspinal. Range of motion was full but painful. Lower extremity motor strength was 5/5 bilaterally. Sensation was normal. The plan was to perform lumbar facet blocks 2 weeks apart.
As of a progress note, it was noted the patient had complaints of ongoing low back pain and reported her pain is getting worse and now is radiating down the leg again, most likely because the previous nerve block has worn off. The pain radiates down the left leg to the knee. On examination, there was full but painful range of motion, normal motor strength, normal sensation, positive facet challenge as well as positive faber. The patient was recommended for a lumbar transforaminal epidural injection at L4, L5, S1.
There is a "diagnostic block evaluation report" that circles lumbar facet, bilateral, using lidocaine, and reported there was 80% reduction in baseline pain.
The patient returned for a follow-up visit regarding low back pain stating that the insurance denied the second facet injection although the patient had greater than 80% pain relief for the length of anesthetic and it lasted about 7.5 hours with improved activities of daily living. The physical exam revealed full range of motion but painful, 5/5 motor strength, normal sensation, negative flip test, positive facet challenge and positive faber. The patient was recommended to undergo bilateral facet injection #2. At issue is the medical necessity of the requested facet injection.

According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, facet injections/medial branch blocks can be considered when there are 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).
In this case, the patient is noted to have complaints of chronic back pain but also has a history of lumbar radiculopathy for which epidural injections were performed. Prior to the facet injection, the progress note  stated the patient had worsening pain radiating down the left leg into the knee and magnetic resonance imaging (MRI) shows severe lateral recess narrowing and moderate to severe bilateral frontal stenosis at L4-L5 as well as up to severe foraminal stenosis at L5-S1. There is no evidence suggesting that the patient's facet joints are the primary pain generator and radiculopathy is exclusionary criterion for facet procedures.
Additionally, evidence-based guidelines recommend only one diagnostic block and if there is a positive response the patient would be expected to proceed with radiofrequency ablation. There is no need for a second medial branch block. Medical necessity is not established.