Is a bilateral facet joint injection (64493 x2, 64494 x2) medically necessary for a patient with spondylosis without myelopathy, sacroiliitis, and lumbar neural canal stenosis, and a history of chronic low back pain?

Medical Necessity Determination for Bilateral Facet Joint Injections

This bilateral facet joint injection request does NOT meet medical necessity criteria because the patient has radiculopathy with numbness/tingling in the right thigh and significant foraminal stenosis on imaging, making facet joint injections inappropriate for this clinical presentation. 1

Critical Exclusion Criteria Present

Radiculopathy is an absolute contraindication to facet joint injections for diagnostic purposes. The American College of Neurosurgery explicitly states that diagnostic facet joint injections are considered insufficient evidence or unproven for neck and back pain with untreated radiculopathy. 1 This patient clearly has:

• Numbness/tingling in the right thigh present for 10 years, worsened over the last 10 months [@Case Documentation]
• MRI showing moderate bilateral foraminal stenosis at L5-S1 [@Case Documentation]
• Pain pattern consistent with radicular symptoms rather than pure facet-mediated pain 1

The presence of radiculopathy fundamentally changes the pain generator from facet joints to nerve root compression, making epidural steroid injections the more appropriate intervention. 1

Additional Unmet Criteria

Inadequate Conservative Treatment Documentation

The patient requires at least 6 weeks of comprehensive conservative treatment before facet injections are considered medically necessary. 1 The documentation shows:

• Physical therapy was completed for the knee (July-August), with only "some low back work" [@Case Documentation]
• No documentation of a structured 6-week lumbar-specific physical therapy program [@2@]
• No chiropractic or massage therapy attempted [@Case Documentation]
• The American College of Neurosurgery requires documented failure of comprehensive conservative management before proceeding to facet interventions 1

Questionable Physical Examination Findings

The physical examination does not clearly confirm facet-mediated pain as the primary pain generator. 1 Key concerns include:

• Kemp's test was positive bilaterally, but this finding alone has poor diagnostic accuracy for facet pain 1
• The American College of Neurosurgery emphasizes that no single physical examination finding reliably predicts facet-mediated pain 1
• Extension was limited with pain, but lateral flexion was negative bilaterally, creating an inconsistent pattern for facet syndrome [@Case Documentation]
• Pain aggravated by lifting, standing, twisting, and walking could represent multiple pain generators including disc pathology [@Case Documentation]

Imaging Shows Alternative Pain Sources

The MRI demonstrates moderate bilateral foraminal stenosis and mild central canal stenosis at L5-S1, which are more consistent with radicular pain than facet-mediated pain. 1 The American College of Neurosurgery requires that imaging studies show no other obvious cause of pain for facet injections to be considered medically necessary. 1 This patient's imaging clearly shows:

• Moderate bilateral foraminal stenosis (a definite alternative pain source) [@Case Documentation]
• Mild-to-moderate degenerative disc and spondylosis changes [@Case Documentation]
• These findings are more consistent with nerve root compression causing the radicular symptoms 1

Evidence Against Therapeutic Benefit

Even if diagnostic criteria were met, the evidence for therapeutic benefit of facet joint injections is extremely limited. 2, 1

• Multiple studies demonstrate that facet joints are not the primary source of back pain in 90% of patients, with only 7.7% achieving complete relief after facet injections 1, 3
• The American College of Neurosurgery notes that multiple studies have failed to demonstrate effectiveness of facet joint injections as a therapeutic intervention for chronic low back pain 1, 3
• Moderate evidence indicates that facet joint injections with steroids are no more effective than placebo injections for long-term relief of pain and disability 1, 3
• The patient already failed a prior transforaminal epidural steroid injection with no pain relief, suggesting that injectables may not be effective for this patient's pain syndrome [@Case Documentation]

Appropriate Alternative Approach

Given the radiculopathy and foraminal stenosis, this patient would be better served by addressing the nerve root compression rather than pursuing facet interventions. 1 The clinical algorithm should be:

1. Complete a structured 6-week lumbar-specific physical therapy program focusing on nerve root decompression techniques and core stabilization [@1@]

2. Consider repeat epidural steroid injections (potentially at a different level or with different technique) since the patient has clear foraminal stenosis causing radicular symptoms 1

3. Only after radiculopathy is adequately treated and if axial back pain persists without radicular symptoms, then reconsider facet joint evaluation with proper diagnostic medial branch blocks using the double-injection technique with ≥80% pain relief threshold [@1