Lumbar Epidural Steroid Injection denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Researchers noted that low back pain continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. One study concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. This patient presented on several dates for follow-up of low back pain with left leg radiation. Initially, the patient reported painful radiculopathy with reduced function and activities of daily living. The patient’s range of motion was decreased due to pain and straight leg raise was positive.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar epidural steroid injection. In this case, the patient has reported significant low back pain. Magnetic resonance imaging (MRI) of the patient’s lumbar spine shows impression of multilevel mild lumbar spine discogenic disease, most pronounced at L3-L4, interval decrease in left foraminal disc protrusion at L4-5 measuring 3 mm and contributing to moderate left lateral recess narrowing, and probable contact traversing the left L5 nerve root. Imaging also shows impression of multilevel mild foraminal stenosis and no significant lumbar spinal canal stenosis. The medical records document prior positive responses to transforaminal epidural steroid injections (TFESIs), which have significantly improved the patient’s lumbar radicular pain.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar epidural steroid injection.Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: the pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. Kreiner and colleagues evaluated the role of epidural spine injection for the treatment of lumbar disc herniation with radiculopathy. They concluded that transforaminal epidural spine injection is recommended to provide short-term (2–4 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lumbar epidural injections at L5-S1. Findings: The physician reviewer found that American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural steroid injections addressed approaches to repeat injections (Manchikanti, et al.). The authors noted that repeat injections should be based on, “The administration must be based solely on patients’ response, the safety profile of the drug, experience of the patient, and pharmacological and chemical properties such as duration of action and suppression of adrenals.” Regarding procedural outcomes, the ASIPP guidelines state that, “In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be two and a half to three months or longer between each injecti…

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Lumbar Epidural Steroid Injectionwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.