Diagnosis: Cervical Disc Herniation
Treatment: Facet joint injections

The insurer denied coverage for facet joint injections.
The denial is upheld .

This patient has had neck pain for several months and reported greater than 80% (percent) improvement from an epidural steroid injection but continued to have axial neck pain. The patient has tried conservative measures for 2 months and her current pain level is 8/10. Results of magnetic resonance imaging (MRI) of the neck showed a left paracentral disc herniation at cervical (C) 5-6 and at C6-C7 resulting in moderate central canal stenosis and severe left foraminal stenosis. A diagnostic cervical medial branch block of bilateral C4/5, C5/6, C6/7 facet joints is requested.

The patient has clear disc pathology which has not been adequately addressed. The pain physician wants to perform further diagnostic tests in the face of an extruded disc. No surgical consultation has been obtained.

In the cervical spine, Bogduk and Aprill (1) assessed the prevalence of discogenic pain and zygapophysial facet joint pain. They showed that discs alone were symptomatic in only 20% of the sample. However, in 41% of the patients, both a symptomatic disc and symptomatic zygapophysial joints were identified.

Here you have a symptomatic disc, no facet arthropathy on MRI and extruded disc material.

In the section on cervical disc herniation, guidelines make no mention of the need for diagnostic blocks (2).

The axial pain the patient is experiencing is probably related to the extruded disc. It is not medically reasonable or necessary to perform diagnostic blocks when an obvious pain generator has been identified.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for facet joint injections is not substantiated. The insurer's denial is upheld.