Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) bilateral medial branch block L3, L4, L5, (2) radiofrequency ablation on the left side of the spine L3, L4, L5, (3) radiofrequency ablation on right side of the spine L3, L4, L5, and (4) bilateral radiofrequency ablation L3, L4, L5. The American Society of Interventional Pain Physicians (ASIPP) guidelines note that the criteria for establishing facet joint related back pain and indications for performing medial branch blocks and radiofrequency ablation include positive axial pain and paraspinal tenderness confirming the diagnosis, the absence of a radicular pattern, pain alleviated with rest, and pain induced by pressure on the facet joint in patients with reduced range of motion. The ASIPP guidelines further note that a diagnostic scale for lumbar pain of facet joint origin includes similar symptoms and signs including axial pain improvement with rest, the absence of a radicular pattern, a positive Kemps sign, pain induced by pressure on the facet joints, and facet stress or new lumbar facet sign. In a review of lumbar medial branch block and radiofrequency ablation procedures, Won and colleagues report, The common indications for both diagnostic and therapeutic facet joint interventions include: (1) average pain levels greater than five on a scale of zero to ten, (2) intermittent or continuous lower back pain causing functional disability, (3) somatic or non-radicular lower back pain and lower extremity pain lasting at least three months, (4) failed conservative treatment, including physical therapy with exercises, chiropractic management, and pharmacologic therapy, (5) lack of preponderance of the evidence of either discogenic or sacroiliac joint pain or evidence of radiculitis, and (6) contraindications or inability to undergo physical therapy or inability to tolerate oral medications. In this case, the patient reports low back pain radiating into the left thigh and leg.  The records note a diagnosis of lumbar radiculopathy. A physical examination revealed positive straight leg tests bilaterally, indicating the presence of lumbar radiculopathy or radiculitis. Given that the ASIPP guidelines are clear that lumbar medial branch blocks and radiofrequency procedures are not indicated in treating patients with chronic low back pain due to lumbar radiculopathy, the services at issue were not medically indicated. Therefore, (1) bilateral medial branch block L3, L4, L5, (2) radiofrequency ablation on the left side of the spine L3, L4, L5, (3) radiofrequency ablation on right side of the spine L3, L4, L5, and (4) bilateral radiofrequency ablation L3, L4, L5 were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine 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.