Epidural Steroid Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a series of three intra-articular injections of hyaluronic acid, a third epidural steroid injection, and celecoxib. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy and epidural steroid injection. Findings: The physician reviewer found that there is a lack of supporting documentation such as chest x-rays, chest computed topography, sinus computed topography, pharmacy antibiotic records or antibiotic log to confirm this diagnosis. A single set of laboratory results show a low total IgG, but there is no repeat of laboratory work up to confirm. Moreover, there is a lack of evaluations for other signs of protein loss, and there is no specific antibody titers of pre- and post- vaccination titers. The records provided do not clearly evaluate the patient’s ability to respond to infections or lack thereof as required for the diagnosis of common variable immunodeficiency (CVID).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for epidural steroid injections and facet joint injections. This patient presents with chronic low back pain radiating into the bilateral lower extremities in an L5-S1 dermatomal distribution with associated complaints of leg weakness. Signs and symptoms are generally consistent with neurogenic claudication and affect ambulatory tolerance. She has been diagnosed with lumbosacral radiculopathy. She has failed to adequately improve with long-term conservative treatment, including activity modification, medications, physical therapy, and home exercise. Her provider has recommended epidural steroid injections and facet joint injections.

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