Recommendation on Medical Necessity
This third lumbar transforaminal epidural steroid injection does NOT meet medical necessity criteria because the submitted documentation fails to demonstrate that the previous injection (#2) provided at least 50% pain relief for at least 2 weeks, increased functional capacity, or reduced pain medication use—all of which are required by the Spine Intervention Society's appropriate use criteria for repeat injections. 1
Critical Missing Documentation
The case fails to meet Aetna's CPB 0722 criteria for additional therapeutic TFESIs, which explicitly requires that the initial injection resulted in at least two of the following for at least 2 weeks: 1
- 50% or greater relief in pain - NOT DOCUMENTED
- Increase in level of function/physical activity (e.g., return to work) - NOT DOCUMENTED
- Reduction in use of pain medication and/or additional medical care such as physical therapy/chiropractic care - NOT DOCUMENTED
Evidence-Based Rationale Against Approval
The Spine Intervention Society's appropriate use criteria explicitly state that repeat injection with steroid is appropriate only if there was at least 50% relief for at least 2 months after the first injection. 1 Without documented evidence of meaningful benefit from the prior injection, repeating the procedure exposes the patient to unnecessary risks.
Risks Without Demonstrated Prior Benefit
Shared decision-making regarding TFESI must include discussion of potential complications including: 1, 2
- Dural puncture
- Insertion-site infections (including methicillin-resistant Staphylococcus aureus epidural abscess) 3
- Cauda equina syndrome
- Sensorimotor deficits
- Discitis
- Epidural granuloma
- Retinal complications
Exposing the patient to these risks without objective evidence of prior benefit from previous injections is not justified. 1
What Would Be Required for Approval
To meet medical necessity for this third injection, the medical record must document that injection #2 resulted in: 1
- Quantified pain reduction: Specific numeric rating scale scores showing ≥50% improvement (e.g., "pain decreased from 8/10 to 3/10")
- Duration of relief: Documentation that this relief lasted at least 2 weeks (preferably 2 months per Spine Intervention Society criteria)
- Functional improvements: Specific activities the patient could perform after injection that they could not before (e.g., "returned to work," "able to walk 30 minutes without stopping," "resumed grocery shopping")
- Medication reduction: Documentation of decreased opioid doses or frequency (particularly relevant given this patient is on Butrans 10 mcg/hr patch, Butrans 20 mcg/hr patch, Belbuca 300 mcg film, AND Tramadol 50 mg twice daily)
Additional Clinical Concerns
Excessive Opioid Burden
This patient is on an extraordinarily high opioid regimen with multiple long-acting formulations plus breakthrough medication. The American Society of Anesthesiologists recommends that epidural steroid injections should be part of a multimodal treatment regimen, not simply added to escalating opioid therapy. 1, 2 The lack of documented medication reduction after previous injections raises questions about treatment efficacy.
Alternative Pain Generators
The American Society of Anesthesiologists emphasizes that clinicians should not ignore alternative pain generators when physical examination suggests their involvement. 1 Given the bilateral nature of the injections (L4-L5 and L5-S1 bilaterally), consideration should be given to whether facet-mediated pain or sacroiliac joint pathology may be contributing to symptoms. 1
Recommendation
DENY medical necessity for the lumbar transforaminal epidural steroid injection performed on the date of service. The clinical documentation does not establish that the previous injection (#2) provided meaningful benefit as measured by pain relief, functional improvement, or medication reduction. 1
The provider should submit additional documentation if available that demonstrates the response to injection #2, including: 1
- Pre- and post-injection pain scores with specific percentages of improvement
- Duration of pain relief in weeks or months
- Specific functional activities that improved
- Changes in pain medication dosing or frequency
Do not repeat injections based solely on patient request without objective evidence of prior benefit. 1 The American College of Physicians emphasizes that epidural injections must be part of a comprehensive program including physical therapy, patient education, psychosocial support, and oral medication optimization. 1
References Supporting Denial
The Spine Intervention Society's appropriate use criteria provide the most specific guidance on repeat injections, requiring documented 50% relief for at least 2 months. 1 The American Society of Anesthesiologists supports epidural steroid injections for radiculopathy but emphasizes they should be part of multimodal treatment with shared decision-making about risks. 1, 2 Without evidence of prior benefit, the risk-benefit ratio does not favor repeating the procedure.