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 formal 6-week dedicated lumbar spine physical therapy program is documented [@2@]
• No chiropractic care attempted (patient states "No chiropractic or massage attempted") [@Case Documentation]

A comprehensive 6-week conservative treatment program specifically targeting lumbar facet-mediated pain must be completed and documented before proceeding with facet injections. 1

Questionable Physical Examination Findings

The physical examination findings do not clearly establish facet-mediated pain as the primary pain generator:

• Positive Kemp's test bilaterally suggests facet involvement [@Case Documentation]
• However, the pain is aggravated by lifting, standing, twisting, and walking - activities that can be associated with multiple pain generators, not exclusively facet joints [@2@]
• Pain relieved by sitting is more consistent with spinal stenosis and radiculopathy than pure facet syndrome 1
• The American College of Neurosurgery emphasizes that no single physical examination finding reliably predicts facet-mediated pain 1

Imaging Shows Alternative Pain Generators

The MRI demonstrates pathology that better explains the patient's symptoms:

• Moderate bilateral foraminal stenosis at L5-S1 - this directly correlates with the radicular symptoms [@Case Documentation]
• Mild central canal stenosis - consistent with neurogenic claudication symptoms [@Case Documentation]
• Mild-to-moderate degenerative disc and spondylosis changes - multiple potential pain generators present [@Case Documentation]

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 has clear alternative pain generators on imaging that better explain the clinical presentation.

Prior Treatment Failure Pattern

The patient's treatment history reveals a concerning pattern:

• Recent bilateral S1 transforaminal epidural steroid injection provided no pain relief [@Case Documentation]
• The patient "presents for follow-up after prior procedure with no pain relief" [@Case Documentation]

This lack of response to epidural steroid injection does not automatically indicate facet-mediated pain. 1 It may indicate:

• Inadequate targeting of the pain generator
• Non-inflammatory pain mechanism
• Central sensitization
• Psychosocial factors contributing to pain persistence

Evidence Against Therapeutic Benefit

Even if diagnostic criteria were met, the evidence for therapeutic benefit of facet joint injections is limited:

• Multiple studies show 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, 2
• 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
• 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, 2

Appropriate Alternative Approach

For this patient with radiculopathy and foraminal stenosis, repeat transforaminal epidural steroid injections at the appropriate levels (L4-5 and L5-S1) would be more appropriate than facet joint injections. 1 If epidural approaches continue to fail, consider:

• Comprehensive physical therapy program specifically targeting lumbar spine for minimum 6 weeks 1
• Evaluation for surgical decompression given moderate foraminal stenosis and failed conservative management [@Case Documentation]
• Pain psychology consultation for chronic pain management strategies given 10-year history [@Case Documentation]

Diagnostic Medial Branch Blocks: Future Consideration

If the patient were to meet all criteria (no radiculopathy, completed 6-week PT, imaging without alternative pain generators), diagnostic medial branch blocks would be more appropriate than intraarticular facet injections. 3, 1

• Medial branch blocks show better evidence for both diagnostic accuracy and therapeutic efficacy compared to intraarticular injections 1
• The gold standard requires controlled comparative local anesthetic blocks (double-injection technique) with ≥80% pain relief 1
• Diagnostic blocks are only medically necessary when radiofrequency ablation is being considered as the definitive treatment 1

Critical Caveat

The plan states "Positive blocks — candidate for RFA" which suggests the physician intends these as diagnostic blocks leading to radiofrequency ablation. [@Case Documentation] However, this diagnostic pathway is inappropriate when radiculopathy is present, as the radicular symptoms must be addressed first before pursuing facet-mediated pain diagnosis. 1

Recommendation: DENY - Medical necessity criteria not met due to presence of radiculopathy with untreated foraminal stenosis, inadequate conservative treatment documentation, and imaging showing alternative pain generators that better explain the clinical presentation. [@