Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve injections for two levels. We decided that the Plan does not have 
to pre-approve the injection for the third level.  
 
You asked the Plan to pre-approve lumbar/sacral facet joint injections. You say that the records provided 
support medical necessity. The Plan says that the criteria for coverage have not been met. 
 
We decided that the Plan has to pre-approve injections for two levels.  
 
The Plan must follow Medicare rules. The rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the 
criteria listed in the Medicare rules section. 
 
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 the injections. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has moderate to severe chronic 
neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale. 
The enrollee's pain has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management. There is an absence of untreated radiculopathy or neurogenic 
claudication. There are no non-facet pathology per clinical assessment or radiology studies that could explain 
the source of the pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections for two levels have been met. Therefore, we decided that the Plan 
has to pre-approve injections for two levels.  
 
We also decided that the Plan does not have to pre-approve the injection for the third level. 
 
The Plan must follow Medicare rules. The rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a 
time period, which includes all procedures that are performed during the same day. 
 
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 the injection for the third level. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
include documentation of unique circumstances and with sufficient documentation of medical necessity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the third injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the injection for the third level. 
 
 
 
 
 
 
 
 
 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.