Cervical Epidural Steroid Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the neck spine with dye and epidural injection for evaluation and treatment of the enrollee’s neck and low back pain. Findings: The physician reviewer found that In general, cervical spine MRIs are recommended due to the emergence of a red flag, physiologic evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative treatment, or clarification of anatomy prior to an invasive procedure. Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology. In this case, the patient presents with worsening neck pain radiating down his arms with associated numbness and tingling.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical epidural steroid injections and four additional follow-up pain management visits for six total pain management follow-up visits to treat the patient’s chronic neck pain. Based on a review of the record, the request cervical epidural steroid injection and four additional follow-up pain management visits for six total pain management follow-up visits are medically necessary to treat the patient’s chronic neck pain. The guidelines for epidural injections indicate that fluoroscopically guided cervical interlaminar epidural injections are strongly recommended in this patient’s clinical setting due to long-term effective pain management.

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.

A 53-year-old female enrollee has requested four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) for treatment of her cervical spondylosis. Findings: The physician reviewer found that four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) is not medically necessary for management of this patient’s medical condition. The imaging studies are significant for multilevel cervical degenerative disc disease and neuroforaminal stenosis. It is difficult to determine the true pathology of the patient’s chronic pain. The medical literature shows evidence for diagnostic facet injections in supporting treatment for facet syndrome. There is no indication for repeat injections two to four weeks apart.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cervical Epidural Steroid Injection, then check the rights and deadlines that apply to your plan.