Diagnosis: lower back pain
Treatment: pain injections (64483 x 1, 64484 x 1)

The insurer denied coverage for pain injections (64483 x 1, 64484 x 1)

The denial is overturned.

This is an adult with a history of lower back pain. The patient had a spinal cord stimulator removed. The patient had an epidural steroid injection (ESI) and reported 100% relief. The patient was treated with physical therapy (PT). The request was to repeat the epidural steroid injection (ESI).

The procedure is medically reasonable and necessary.

Kwak et al evaluated the long-term outcomes of Transforaminal Epidural Steroid Injections (TFESI) in patients with lumbosacral radicular pain due to a Herniated Lumbar Disk (HLD) by the location, type, and size of the HLD.

In total, 114 patients who received the initial TFESI at least 4 years ago completed a telephone interview. They investigated the presence of radicular pain, degree of current pain, current pain medications and TFESIs, additional TFESIs, progression to surgery, and trouble in performing daily life activities and occupational job duties. They classified the included patients by the location, type, and size of the HLD, and evaluated whether these factors affected the long-term outcomes of TFESI.

At least 4 years after the initial TFESI, radicular pain was completely resolved in 45% of the patients. However, 30% patients were on oral painkillers or repetitive TFESIs or had undergone surgery and 15% had difficulty in performing daily life activities and occupational job duties. A larger number of patients with extruded lumbar disc herniation required additional TFESIs than those with protruded lumbar disc herniation. Apart from this, the outcomes did not significantly differ by the location, type, and size of the HLD. [1]

A Cochrane review found moderate-quality evidence that epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain and disability at short-term follow-up. The treatment effects were small, however, and may not be considered clinically important by patients and clinicians. We identified mostly minor adverse events (e.g., headache, accidental dural punctures, worsening pain) after epidural corticosteroid injections and placebo injections and very low-quality evidence that there is no difference between groups. Long term follow-up (greater than 12 months) found modest effects. [2]

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 pain injections (64483 x 1, 64484 x 1) is substantiated.