Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injections and facet joint injections. This patient presents with chronic low back pain radiating into the bilateral lower extremities in an L5-S1 dermatomal distribution with associated complaints of leg weakness. Signs and symptoms are generally consistent with neurogenic claudication and affect ambulatory tolerance. She has been diagnosed with lumbosacral radiculopathy. She has failed to adequately improve with long-term conservative treatment, including activity modification, medications, physical therapy, and home exercise. Her provider has recommended epidural steroid injections and facet joint injections. With regard to the requested epidural steroid injections, the Agency for Healthcare Research and Quality (AHRQ) reported on a comparative effectiveness study evaluating injection therapies for low back pain. The AHRQ found that epidural steroid injections for radiculopathy were associated with immediate improvement in pain and possibly in function. However, the authors noted that the benefits were small and temporary, and there was no effect on the long-term risk of surgery. The limited evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or non-radicular back pain. Smith and colleagues concluded that there was strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. The authors noted that there is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis. Given these findings, the requested epidural steroid injections are not medically necessary for this patient. In addition, the requested facet joint injections are not clinically indicated, as the medical records do not meet the evidence-based requirements. Studies concluded that despite the debate regarding appropriate use of therapeutic modalities in managing lumbar facet joint pain, the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. Cohen and colleagues reported that therapeutic facet injections have short-term utility, but multicenter randomized trials are needed to ascertain the best way to diagnose facet joint pain, confirm the efficacy of radiofrequency ablation, and determine which patients benefit most from the injections. Based on current data, facet joint injections are not supported in the setting of radicular pain. The patients records do not include clinical examination findings supporting facet-mediated pain limited to specific levels. Moreover, there is no discussion of imaging findings relative to facet joint pathology or other potential pain generators. For these reasons, the requested facet joint injections are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.