Are repeat facet injections (64493, 64494, 64495), sacroiliac joint (SIJ) injections (27096), trigger point injections (20553), and initial caudal epidural steroid injection (ESI) (62323) medically necessary for a patient with low back pain, who had 50-60% significant improvement after previous injections, but has recurrence of pain?

Determination: Repeat Facet Injections NOT Medically Necessary; SIJ and Trigger Point Injections Approved; Caudal ESI Approved but Should NOT Be Combined at Same Visit

Critical Issue: Failure to Meet 80% Relief Threshold for Repeat Facet Injections

The repeat bilateral L3-S1 facet joint injections (64493,64494,64495) are NOT medically necessary because the patient achieved only 50-60% pain relief from the previous injections, which fails to meet the established 80% relief threshold required for repeat diagnostic/therapeutic facet interventions. 1, 2, 3

• The American College of Neurosurgery explicitly states that a second diagnostic facet injection is considered medically necessary only when the initial injection produced a positive response defined as ≥80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic 1
• The American Society of Interventional Pain Physicians (ASIPP) 2020 guidelines establish Level I-II evidence with strong recommendation that controlled comparative local anesthetic blocks with a concordant pain relief criterion standard of ≥80% should be used for diagnosis 2
• The multispecialty international consensus guidelines confirm that more stringent selection criteria (higher relief thresholds) improve denervation outcomes, though at the expense of more false-negatives 3

Clinical Pitfall: The 50-60% relief suggests the facet joints may not be the primary pain generator. Only 7.7% of patients selected for facet injection based on clinical criteria achieve complete relief, and facet joints are not the primary source of back pain in 90% of patients 1, 4

Approved Procedures with Important Caveats

Bilateral Sacroiliac Joint Injections (27096) - APPROVED

The bilateral SIJ injections are medically necessary as this appears to be the second set of therapeutic injections, meeting Aetna criteria. 5

• Up to 2 therapeutic/diagnostic sacroiliac injections are considered medically necessary to diagnose pain and achieve therapeutic effect 5
• The patient demonstrated positive response to previous SIJ injections with "appeared to be doing much better following SIJ injections" documented 5
• Clinical examination supports SIJ pathology: left sacroiliac joint was extremely tender, positive step test with predominance to the left, and MRI showing bilateral SI joint inflammation 5

Trigger Point Injections (20553) - APPROVED

The trigger point injections are medically necessary as the patient has documented myofascial pain with trigger points and has not exceeded the 4-set limit. 6

• Up to 4 sets of injections are considered medically necessary to diagnose the origin of pain and achieve therapeutic effect 5
• Clinical examination documented gluteal myofascial triggers bilaterally and left paravertebral myofascial triggers with increased muscle tone 6
• The Journal of Neurosurgery provides moderate evidence that trigger point injections have therapeutic value for selected patients with myofascial pain, though relief is typically short-term 6

Important Caveat: Trigger point injections should not be repeated more frequently than every 7 days, and if no clinical response is achieved after 4 sets, additional injections are not medically necessary 5

Caudal Epidural Steroid Injection (62323) - APPROVED BUT TIMING ISSUE

The initial caudal ESI meets medical necessity criteria based on radicular symptoms and imaging findings, BUT should NOT be performed at the same visit as the other injections. 1

Medical Necessity Criteria Met:

• Pain is radicular in nature: documented right lower limb leg and foot pain radiating below the knee 1
• Advanced imaging within 24 months: MRI shows L4-L5 and L5-S1 degenerative disc disease with moderate foraminal stenoses bilaterally and spinal nerve displacements 1
• Failed conservative treatment: chronic pain since age [AGE] with current medications (lidocaine patch, naproxen, gabapentin, amitriptyline) and physiotherapy 1
• Part of comprehensive pain management program: patient engaged in physiotherapy with guidance on core stability and posture 1

Critical Scheduling Conflict:

The Aetna CPB policy explicitly states that "only one invasive modality or procedure will be considered medically necessary at a time," which directly contradicts performing multiple injection types at the same visit. 1

• This policy exists to allow proper assessment of each intervention's individual therapeutic effect 1
• Combining procedures prevents accurate determination of which intervention provided benefit, compromising future treatment decisions 1
• The ASIPP guidelines recommend Level I evidence with strong recommendation for mandatory fluoroscopic guidance for all facet joint interventions, which requires separate procedural focus 2

Recommended Treatment Algorithm

Immediate Plan (First Visit):

1. Perform bilateral SIJ injections (27096) ONLY - highest likelihood of benefit based on previous positive response and clinical findings 5
2. Defer all other procedures to allow assessment of SIJ injection efficacy 1

Second Visit (If Needed, Minimum 7 Days Later):

1. If SIJ injections provide <50% relief: Proceed with caudal ESI (62323) for radicular component 1
2. Add trigger point injections (20553) if myofascial pain persists as a separate component 5

Alternative Consideration for Facet Pain:

Rather than repeat facet injections with suboptimal previous response, consider radiofrequency ablation (RFA) of medial branch nerves if patient had ≥50% relief for at least 2 months. 4, 2

• The American Society of Anesthesiologists recommends conventional radiofrequency ablation as the "gold standard" for treating facetogenic pain when diagnostic blocks provide temporary relief with ≥50% pain relief 1, 4
• Level II evidence with moderate strength of recommendation supports lumbar radiofrequency ablation for both short-term and long-term pain relief 2, 7
• RFA provides average pain relief of 15 weeks per intervention, with some patients experiencing relief for 44-45 weeks 6

Summary of Determinations

Procedure	Medical Necessity	Rationale
Bilateral L3-S1 Facet Injections (64493,64494,64495)	DENIED	Failed to achieve 80% relief threshold; only 50-60% improvement documented [1,2]
Bilateral SIJ Injections (27096)	APPROVED	Meets criteria for second therapeutic injection with documented previous benefit [5]
Trigger Point Injections (20553)	APPROVED	Documented myofascial triggers, within 4-set limit [6,5]
Caudal ESI (62323)	APPROVED with modification	Meets medical necessity but must be performed at separate visit per "one invasive procedure per visit" policy [1]

The fundamental issue is that performing all approved procedures together violates the established policy of one invasive modality per visit, which exists to ensure proper assessment of individual treatment efficacy and guide future management decisions. 1