Transforaminal Epidural Steroid Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

The enrollee is requesting authorization and coverage for transforaminal epidural steroid injections, Norco 10/325, and Flexeril, 10mg. The enrollee has low back and right leg pain. The enrollee received a right lumbar transforaminal block. She has chronic, disabling pain, which has caused psychological, social, and physical impairment. Conservative treatments have been used without relief. These include non-steroidal anti-inflammatory drugs and physical therapy. The record indicated her blood level of Norco was within normal limits and her urine toxicology screen was also normal, with no use of illicit substances. The enrollee indicates with her current pain medications, she was able to feel better, sleep more and be more active. She did not report any side effects related to the pain medication.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transforaminal epidural steroid injections. The researchers guidelines for epidural steroid interventions state, “For thoracic disc herniation, based on one relevant, high-quality randomized controlled trial (RCT) of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.” In a systematic review and meta-analysis of epidural injections for lumbar radiculopathy or sciatica, researchers report, “A comparative systematic review and meta-analysis of the Cochrane Review of RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transforaminal epidural steroid injections for treatment of the enrollee's chronic low back pain. Findings: The physician reviewer found that evidence based medical guidelines support the use of epidural steroid injections as a possible option for the treatment of radicular pain defined as pain in dermatomal distribution with corroborative findings of radiculopathy. On the other hand, medical evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or non-radicular back pain. The criteria for epidural steroid injections include radiculopathy documented by physical examination and corroborated by imaging studies and/or electrodiagnostic studies. Furthermore, patients should have been initially unresponsive to conservative treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Anesthetic Injection (CPT64483), Epidural Injection (CPT 64484), and Dexamethasone Sodium Phosphate Injection (HCPCS J1100).In this case, the patient has a history of low back and left hip pain with radiculopathy to the left leg. Records show that the patient’s pain interferes with activities of daily living. She has reported significant relief of pain and improved activities of daily living with the pain medication Norco. She has been diagnosed with lumbago with left sciatica. She has undergone multiple transforaminal epidural steroid injections on the left at L4, L5, and S1 with reported improvement in pain and function. The patient’s pain management physician has requested authorization for a left sided transforaminal epidural steroid injection.

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