Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet joint injections to the lumbar and lumbosacral spine (CPT codes 64493, 64494, 64495, and J1100) are not medically necessary for the treatment of this patient. Scientists conducted a randomized controlled clinical trial to establish the long-term efficacy for intraarticular and medial branch facet blocks for chronic pain. The authors found that, facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. In conclusion, the authors noted that, facet joint injections appear to have little long-term utility, though they may provide prognostic value compared to control injections before radiofrequency ablation.  Researchers reported that intra-articular lumbar facet joint corticosteroid injections are effective, regardless of facet joint osteoarthritis severity. However, the study was limited by its retrospective design and small sample size. Additionally, the authors did not assess the long-term effects of intraarticular lumbar facet joint corticosteroid injections. This patient presents with a history of chronic low back pain, reported to be moderate to severe, with limitations noted in her functional activities. Clinical examination findings document severe lumbar paraspinal muscle spasms from L1-S1 and moderately reduced lumbar extension and lateral rotation range of motion. There are no focal neurologic deficits. She has been diagnosed with lumbar and lumbosacral spondylosis without myelopathy or radiculopathy. Treatment has included therapeutic facet joint injections every three to four months and pain medications. She has reported 80% improvement with prior facet joint injections. She also underwent bilateral L4, L5, and S1 therapeutic facet joint injections. Current evidence-based medical literature does not support the ongoing use of therapeutic facet joint blocks as safe and effective. Within the submitted medical records, there are no clinical examination findings of facet-mediated pain limited to specific levels, discussion of imaging findings relative to facet joint pathology or other potential pain generators, or imaging reports. Additionally, there is a lack of support for ongoing facet blocks in lieu of radiofrequency ablation as recommended by current peer-reviewed medical literature. For these reasons, the requested facet joint injections to the lumbar and lumbosacral spine (CPT codes 64493, 64494, 64495, and J1100) are not medically necessary for the 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.