Epidural Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cervical/thoracic interlaminar epidural injection and/or sacroiliac joint injection. With regard to the request for cervical epidural steroid injection, there is medical evidence supporting this treatment modality in specific patients. Medical literature noted that, “repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection.” This patient’s records document chronic neck pain with a diagnosis of cervical radiculopathy and severe degeneration with a C5-6 and C6-7 disc herniation with stenosis. The provider notes that the patient is experiencing neck pain and bilateral upper extremity paresthesias.

Physician 1: The patient is a 62-year-old female who has a long history of back pain. She indicates she benefited from an epidural injection she received in 2003. The patient has tried and failed physical therapy and pain medications. She has requested authorization and coverage for another epidural injection. The Health Plan has denied this request indicating the requested injection is considered experimental and not a covered benefit.The use of epidural steroid injections has been addressed in a recent guidelines statement by the American Society of Interventional Pain Physicians with a determination of moderate evidence of short-term relief for interventional injections. The patient has completed her non-operative treatment program without change in symptoms. An epidural injection was helpful in the past and is medically appropriate and reasonable in this situation.

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: 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…

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 Epidural Injection, then check the rights and deadlines that apply to your plan.