Radicular Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injection(s). The American Society of Interventional Pain Physicians (ASIPP) recently published guidelines regarding evidence supporting epidural steroid injections in the treatment of patients with chronic spinal pain (Manchikanti, et al.). The ASIPP guidelines noted that for patients with spinal stenosis “The evidence based on one high-quality randomized controlled trials in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation.” In addition, “The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality…

The patient is a 39-year-old female who has had low back pain for over a year with intermittent episodes of left leg radicular pain. An MRI of the lumbar spine performed in October 2004 showed grade I spondylolisthesis at L5-S1 and a bulging disc at L4-5. The patient was recently seen by an orthopedic surgeon for acute exacerbation of her left leg pain and numbness and was started on medication as of September 2005. An MRI was ordered at that time, but authorization was denied by the Health Plan. The patient had no improvement and saw her provider again in October 2005, at which time they discussed surgical intervention. The patient indicated she was unable to do much physiotherapy due to her pain and discomfort. Authorization for an MRI was requested again and denied.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for lumbar and neck epidural corticosteroid (steroid) injections and/or bilateral ankle arthroscopy and bilateral knee arthroscopy followed by rehabilitation and physical therapy (PT) services.Lumbar transforaminal injection of steroid (LTFIS) is a treatment for radicular pain. Steroids are believed to have a therapeutic effect due to their anti-inflammatory properties. Smith and colleagues concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. The authors indicated that there is a lack of high-quality evidence demonstrating their effectiveness in the treatment of radicular pain due to spinal stenosis.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for morphine. Researchers found adequate evidence to support short-term efficacy of opioids for chronic low back pain compared to placebo. Researchers determined that for patients “with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses.” Overall, researchers found that there is a paucity of evidence supporting the long-term efficacy of opioid medications for patients with chronic low back pain. Further, researchers reported on an outcome study on the effects of opioid therapy for lumbar disc herniation. Researchers found that patients who were treated with opioids had “significantly worse baseline pain and quality of life.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for radicular pain was denied, the published record says the denial is worth fighting.