Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve medial branch blocks at two levels. We decided that the Plan does 
not have to pre-approve medial branch blocks at an additional level over two.  
 
You asked the Plan to pre-approve medial branch blocks (MBBs) of L2-L3, L3-L4 and L4-L5. You say that 
you disagree with the Plan's denial. The Plan says that the requested services are not medically necessary. 
 
We decided that the Plan has to pre-approve medial branch blocks at two levels.  
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are covered for certain 
indications.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve medial branch blocks of L2-L3, L3-L4 
and L4-L5. Our reviewer says that the documentation supports that the requested services are medically 
necessary at two levels. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has 
had sacroiliac joint injection and epidural steroid injections in the past. The enrollee had radiofrequency 
ablation (RFA) of L2-L4 and L5 dorsal rami in August of 2019. It has been more than two years since the prior 
RFA. Therefore, the diagnostic MBBs should be repeated. However, the utilization limit is two levels per 
session.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks of L2-L3, L3-L4 and L4-L5 have been met. Therefore, we 
decided that the Plan has to pre-approve medial branch blocks at two levels.  
 
We also decided that the Plan does not have to pre-approve medial branch blocks at an additional level 
over two. 
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered for up to two 
levels at one time.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve medial branch blocks at an additional 
level over two. Our reviewer says that the documentation supports that the requested services are medically 
necessary at two levels. Our physician reviewer found it has been more than two years since the prior RFA. 
Therefore, the diagnostic MBBs should be repeated. However, the utilization limit is two levels per session. 
Therefore, only two levels can be covered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks at an additional level over two. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve medial branch blocks at an additional level 
over two. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.