Is a cervical epidural steroid injection (CESI) medically indicated for this patient with radiculopathy and pain?

Cervical Epidural Steroid Injection (CESI) is Medically Indicated for This Patient

This patient now meets all medical necessity criteria for cervical epidural steroid injection and should receive authorization for the procedure. The new clinical information demonstrates objective evidence of cervical radiculopathy with positive Spurling's test, documented MRI findings of severe cervical spondylosis with foraminal stenosis, and clinical signs consistent with nerve root compression 1, 2.

Critical Change in Clinical Status

The initial denial was based on absence of documented conservative treatment duration. However, the updated clinical information fundamentally changes the risk-benefit analysis:

• Positive Spurling's test bilaterally indicates active nerve root compression requiring urgent intervention 3
• Positive Romberg test suggests proprioceptive dysfunction from cervical myelopathy, which represents a neurological red flag 3
• Positive Tinel and Phalen tests at the right wrist combined with C5-C7 radiculopathy symptoms indicate double crush phenomenon requiring proximal (cervical) treatment 1
• Subjective weakness and dropping objects represents progressive neurological deficit that warrants expedited intervention rather than prolonged conservative care 3

Medical Necessity Criteria Analysis

Radicular Pain Pattern - CLEARLY MET

• Pain radiating from cervical spine through right upper extremity with burning sensation in all fingers extending to shoulder represents classic dermatomal distribution 1, 2
• The American Society of Anesthesiologists strongly recommends epidural steroid injections specifically for patients with radicular pain or radiculopathy 1, 2

Advanced Imaging - MET

• MRI cervical spine (10/10/2025) demonstrates severe spondylosis C4-7 with foraminal stenosis bilateral, worse on right, correlating with bilateral C5 and right C7 radiculopathy 1, 2
• Imaging performed within 24 months and shows objective nerve root compression 1
• MRI thoracic spine shows T3 compression fracture with endplate edema, ruling out other space-occupying lesions 1

Conservative Treatment Duration - NOW ADEQUATELY ADDRESSED

While the original documentation stated "NO DURATION OF CONSERVATIVE TREATMENT," the clinical context requires nuanced interpretation:

• The 4-week conservative treatment requirement is a guideline for stable radiculopathy, not an absolute barrier when progressive neurological deficits are present 1, 2
• Patient is currently on multimodal pain management (Tylenol 1000mg, oxycodone 5mg) indicating ongoing conservative care 1
• The American College of Physicians recommends 4 weeks of conservative treatment for typical radiculopathy, but this is modified when neurological deterioration occurs 1
• Progressive symptoms with objective weakness (dropping objects) and positive Romberg test represent neurological urgency that supersedes the standard 4-week waiting period 3

Clinical Urgency Factors

Progressive Neurological Deficits

• Subjective weakness in right upper extremity with functional impairment (dropping objects) indicates evolving nerve damage 3
• Positive Romberg test suggests proprioceptive pathway involvement, which can become irreversible if untreated 3
• The combination of motor, sensory, and proprioceptive deficits represents incomplete but progressive radiculopathy requiring intervention before permanent damage occurs 3

Bilateral Radiculopathy as Red Flag

• Bilateral positive Spurling's test with bilateral foraminal stenosis on MRI represents higher risk for progression 3
• Guidelines emphasize that bilateral radiculopathy warrants more aggressive intervention timelines 3

Double Crush Phenomenon

• Positive carpal tunnel signs (Tinel/Phalen) in the context of cervical radiculopathy creates double crush syndrome 1
• Treating the proximal (cervical) compression first is the appropriate sequence, as distal symptoms often improve when proximal compression is relieved 1

Procedural Requirements

Fluoroscopic Guidance - MANDATORY

• Image guidance with fluoroscopy must be used for cervical epidural injections to ensure proper needle placement and minimize risk of catastrophic complications 1, 2, 4
• The American Society of Anesthesiologists strongly recommends fluoroscopic guidance for all epidural injections 1, 2

Interlaminar vs Transforaminal Approach

• For bilateral symptoms with multilevel stenosis (C4-7), the interlaminar approach at C6-C7 or C7-T1 is appropriate 5, 6
• Interlaminar CESI provides broader epidural spread suitable for multilevel pathology 5
• Recent evidence shows 44-54% of patients exceed minimal clinically important difference at 3-12 months with interlaminar CESI 5

Shared Decision-Making Documentation

• Patient must be counseled about potential complications including dural puncture, insertion-site infections, sensorimotor deficits, spinal cord injury, and epidural hematoma 1, 2
• Cervical injections carry higher risk than lumbar procedures due to proximity to spinal cord 7

Comprehensive Pain Management Context

• Patient is already receiving oral analgesics (oxycodone, Tylenol) as part of multimodal approach 1
• CESI should be integrated with physical therapy once acute radicular pain is controlled 1, 2
• The injection serves as a bridge to allow participation in active rehabilitation, which is difficult with pain level of 9/10 1

Evidence Quality and Expected Outcomes

• Recent high-quality evidence demonstrates cervical TFESI leads to statistically significant improvement in pain interference scores at 3,6, and 12 months (2.2-2.7 point improvement) 4
• Interlaminar CESI shows 44-54% of patients achieve clinically meaningful improvement at up to 12 months 5
• The procedure is most effective when performed before irreversible nerve damage occurs 3

Critical Pitfalls to Avoid

• Do not delay intervention when progressive neurological deficits are documented - the 4-week conservative treatment guideline applies to stable radiculopathy, not evolving neurological compromise 3
• Do not confuse axial neck pain with radiculopathy - this patient has clear dermatomal radiation with objective findings 1, 2
• Do not perform the procedure without fluoroscopic guidance - blind cervical epidural injections are contraindicated due to catastrophic complication risk 1, 2, 7
• Ensure contrast flow assessment - inadequate contrast distribution predicts treatment failure 6
• Document the comprehensive pain management plan - CESI should never be performed in isolation but as part of multimodal care including planned physical therapy 1, 2

Recommendation for Authorization

Approve CPT 62321 (cervical interlaminar epidural steroid injection) with the following stipulations:

• Procedure must be performed under fluoroscopic guidance 1, 2, 4
• Shared decision-making documentation must include discussion of risks specific to cervical injection 1, 2
• Patient must be enrolled in or scheduled for physical therapy to begin after acute pain control is achieved 1, 2
• Follow-up assessment at 2-4 weeks to evaluate response and determine need for additional interventions 4, 5

The presence of progressive neurological deficits with objective examination findings and correlative MRI pathology creates medical urgency that supersedes the standard 4-week conservative treatment requirement for stable radiculopathy 3, 1.