Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) and 
injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or 
CT), lumbar or sacral, each additional level (64484). 
 
You asked the Plan to pre-approve injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the notes do not show that the enrollee's pain decreased by half. The notes 
also do not show the enrollee was able to perform normal activities for at least three months. As a result, this 
injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of low back pain and right lower extremity pain, felt to be consistent 
with radiculopathy. The records show that she underwent right L5-S1 transforaminal epidural steroid injections 
(ESIs) on May 1, 2023. The submitted information states that the enrollee experienced 65% relief of pain for 
six days before the pain began to return. At the 14-day call back, the enrollee reported 0% relief of pain. 
According to the coverage criteria, a repeat ESI, when the first injection directly and significantly provided 
improvement of the condition being treated, may be considered medically reasonable and necessary when the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using the same scale for at least three (3) months. If an enrollee fails to respond well to 
the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or medication 
if appropriate, with the rationale and medical necessity for the second ESI documented in the medical record. 
In this case, the provider is requesting repeat TESIs at the same two levels on the right side, by the same 
transforaminal approach. There is also no documentation that the provider will be using different medications. 
The request does not meet the coverage requirements of the applicable LCD (L33906). The review has 
determined that the enrollee does not meet criteria for approval of the injections. The injections are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance 
(fluoroscopy or CT), lumbar or sacral, single level (64483) and injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(64484).