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 facet injections and Percocet 10mg (60 per 30 days). The current medical evidence does not support facet injections in this clinical setting. A randomized control trial regarding the use of facet joint blocks concluded that facet blocks are not therapeutic (Cohen, S., et al.). The trial also concluded that higher responder rates in certain treatment groups suggested that facet blocks might provide prognostic value before radiofrequency ablation. American Society of Interventional Pain Physicians (ASIPP) guidelines for interventional techniques in chronic spinal pain stated that the evidence for therapeutic lumbar facet joint blocks is weak.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections for treatment of the enrollee’s knee pain. Findings: The physician reviewer found that nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Zilretta injection in the right knee. The records indicate that this patient is being treated for osteoarthritis of the right knee and pain in the right knee. The patient’s right knee pain was improved by nearly 100% with a Zilretta injection and lasted almost three months. The patient reported that the benefits of the Zilretta injection are gradually wearing off. She has noticed more burning pain over the medial aspect of her knee without radiation. Her pain is worse with prolonged walking and standing and better with sitting and rest. Physical examination of the right knee revealed a small effusion with a range of motion from 0-120 degrees with guarding and crepitus. The knee is unstable with 1+ laxity with valgus stress at 0, 30, and 90 degrees and the patellar grind is positive.

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