Facet Joint 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 reimbursement for (1) facet joint injection to the right cervical thoracic region and (2) facet joint injections to the lumbar region. In a systematic review of lumbar facet joint injections and medial branch blocks for chronic low back pain, medical literatures reported that steroids promoted a reduction of numeric rating scale (NRS) by 28% and an improvement of the Oswestry Disability Index (ODI) by 13.2%.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a facet joint injection procedure (CPT 64493).Patients with chronic low back pain of facetogenic origin comprise 15% to 45% of all low back pain patients based on the criteria of the International Association for the Study of Pain. The treatments utilized in managing chronic low back pain of facetogenic origin include intraarticular injections, medial branch nerve blocks, and radiofrequency ablation of medial branch nerves. A randomized controlled trial performed to evaluate the effectiveness of lumbar facet joint nerve blocks found that participants experienced significant improvement with significant pain relief (ClinicalTrials.gov Identifier: NCT00355914). The trial included 60 patients in Group I with local anesthetic, and 60 patients in Group II with local anesthetic and steroid.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography angiography (CTA), facet joint injections and nerve blocks for treatment of the enrollee, who has a history of degenerative disc disease and neck pain. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The American College of Radiology states that CTA may be indicated if spinal arteriovenous malformations or dural arteriovenous fistulae are considered to be likely causes of slow progressive myelopathy and may also be useful in evaluating the intra-cranial and extra-cranial blood vessels for patients with sudden development of a single focal neurological deficit suggesting a vascular ischemic event such as an infarction.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facet injections and/or oxycodone. With regard to the request for oxycodone, the Centers for Disease Control and Prevention (CDC) issued guidelines for the use of opioid medications in patients with non-cancer related pain for initiation, monitoring, and discontinuation. Specifically, the CDC guidelines state that opioids should only be considered when non-opioid and non-pharmacologic interventions have been ineffective, and when selected, should be used at the lowest dose that is effective and minimize opioid-related complications and risks including overdose. In addition, professional opioid management should include consultation to determine compliance as well as urine toxicology screening and an opioid use contract between the provider and the patient.

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