Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Pain Management.
The insurer denied epidural steroid injections.
The denial is upheld in whole.

The patient is a female diagnosed with lumbar radiculopathy. Records indicate the patient underwent lumbar epidural steroid injections. Records indicate that coverage for these epidural injections were denied by the health plan as not medically necessary due to lack of conservative therapy.
The subject under review is the medical necessity for the epidural steroid injections.

The health plan's determination is upheld in whole.

No, the requested health service/treatment of Epidural Steroid injections is not medically necessary for this patient.
The patient was noted to have low back pain with radicular symptoms. However, the magnetic resonance imaging (MRI) does not show nerve compression at the level to be injected.
Additionally, the documentation submitted does not show that the patient tried and failed at conservative treatment to include exercise, physical or chiropractic therapy, and medications such as nonsteroidal anti-inflammatory drugs and/or muscle relaxants, or documentation of current participation in the a physical therapy or home exercise program after the first injection. The procedure report states the patient has tried physical therapy which only helps temporarily, however there were no therapy notes provided, dates of therapy, duration, and it was specifically stated that the patient reported symptoms starting about 2 to 3 weeks prior to this, and therefore the patient has not had six weeks of therapy for this condition. She was noted to have acute low back pain. It was also stated she preferred not to take non-steroidal anti-inflammatory drugs (NSAIDs) due to history of gastrointestinal (GI) ulcers in the past, though there was no indication she had tried other medications.
Based upon the standard of care, it would not be considered standard of care to undergo injection therapy prior to having an appropriate course of conservative management tried and failed, typically including at least 6 weeks of physical therapy and/or chiropractic treatment combined with daily compliance with a home exercise program (HEP) in addition to appropriate pharmacological treatments.
Therefore, based upon the standard of care, medical necessity is not established.