Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve facet joint injections. We decided that the Plan does not have to
pre-approve moderate sedation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan says that the
records show that the request is for facet joint injections, but do not tell whether the injections are diagnostic,
therapeutic, intra-articular, or a medical branch block.

We decided that the Plan has to pre-approve facet joint injections.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet specific criteria.

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 for facet joint injections. Our reviewer says that the
injections themselves are medically reasonable and necessary. Our physician reviewer found that the record
indicates that the enrollee has moderate to severe low back pain on a pain scale that has been exacerbated over
the past four months and failed a six-week conservative therapy program including a home exercise program.

The record does not indicate the presence of radiculopathy. Imaging does not reveal non-facet pathology. The
record indicates that a diagnostic block is requested at L3-L4 and L4-L5. The elements of the coverage criteria
are satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have been met. Therefore, we decided that the Plan has to
pre-approve facet joint injections.

We also decided that the Plan does not have to pre-approve moderate sedation.

The Plan follows Medicare rules. Medicare rules say that neither conscious sedation nor Monitored Anesthesia
Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks.

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 moderate sedation. Our reviewer says
that the requested sedation is not medically reasonable or necessary. Our physician reviewer found that the
record does not establish the medical necessity or reasonableness, as defined by Medicare rules, of the need for
monitored anesthesia care services. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of moderate sedation have not been met. Therefore, we decided that the Plan does
not have to pre-approve moderate sedation.

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.