Diagnosis: Leg pain
Treatment: Injection to treat pain and/or tingling in leg (procedure code 64483)
The insurer denied coverage for injection to treat pain and/or tingling in leg (procedure code 64483).
The denial is overturned.

This patient has bilateral leg pain and numbness. He is taking Methocarbamol, Lyrica and Tylenol for pain. The patient had a trial of physical therapy. His magnetic resonance imaging (MRI) shows moderate to severe spinal stenosis at lumbar (L)3-L4. The request is for bilateral transforaminal epidural steroid injections.

The use of Epidural steroids in this case is supported by:

A recent Cochrane review of epidural steroid injections was published and found in "25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD -4.93, 95% CI -8.77 to -1.09 on a 0-100 scale), short-term disability (MD (mean difference)-4.18, 95% CI (confidence interval): -6.04 to -2.17 on a 0-100 scale) and may be slightly more effective in reducing short-term overall pain (MD -9.35, 95% CI -14.05 to -4.65 on a 0-100 scale). There were mostly minor adverse events (without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR (risk ratio) 1.14, 95% CI: 0.91-1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency.

They concluded: A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence."

Evidence based clinical practice guidelines also support the performance of an epidural injection.

There is insufficient evidence to make a recommendation for or against the use of physical therapy or exercise as stand-alone treatments for degenerative lumbar spinal stenosis.

Interlaminar epidural steroid injections are suggested to provide short-term (2 weeks to 6 months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term (21.5-24 months) efficacy.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for injection to treat pain and/or tingling in your leg (procedure code 64483) is substantiated.