Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for thoracic interlaminar epidural steroid injections. There is a paucity of controlled studies in current medical literature to support this treatment modality at issue as more beneficial than standard treatments. In a systematic evaluation of thoracic interlaminar epidural injections, researchers report, There is a paucity of literature on the use of epidural injections for the treatment of chronic mid and upper back pain due to disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post surgery syndrome, and post thoracotomy pain syndrome. The authors further report, The results of this systematic review evaluating the effectiveness of thoracic epidural injections with or without steroids in managing chronic thoracic pain shows fair evidence with one randomized trial in patients with various causes; whereas the evidence is limited based on one non-randomized study evaluating chronic pain in post thoracotomy syndrome. The authors conclude, The evidence based on this systematic review for thoracic epidural injection in treating chronic thoracic pain is considered fair and limited for post thoracotomy pain. Regarding the effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain, researchers conclude, The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas it is fair for local anesthetics with or without steroids, for axial or discogenic pain, pain of central spinal stenosis, and pain of post surgery syndrome. While the American Society of Interventional Pain Physicians (ASIPP) notes, For thoracic disc herniation, based on one relevant, high-quality randomized controlled trial (RCT) of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. However, the guidelines acknowledge, The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. In this case, the patient was being treated for thoracic spine pain with diagnoses of herniation of intervertebral disc of thoracic region and thoracic radiculopathy. The patient underwent three thoracic interlaminar epidural steroid injections. However, there is a paucity of literature on the use of epidural injections for the treatment of chronic mid and upper back pain due to disc herniation and radiculitis, axial or discogenic pain, spinal stenosis, post surgery syndrome, and post thoracotomy pain syndrome. Therefore, thoracic interlaminar epidural steroid injections were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the thoracic interlaminar epidural steroid injections at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. Physician reviewers 2 and 3 are board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts 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.