Is a third right L2-3 Transforaminal Epidural Steroid Injection (TFESI) and a left L4-5 TFESI medically necessary for a patient with lumbar radiculopathy?

Medical Necessity Determination: Third Right L2-3 and Left L4-5 TFESI

Based on the available clinical documentation, these transforaminal epidural steroid injections do NOT meet medical necessity criteria because there is insufficient documentation of prior treatment response, failed conservative therapy, and radiologic correlation with symptoms.

Critical Documentation Deficiencies

The case fails to meet established criteria on multiple fronts:

Lack of Prior Response Documentation

• The clinical note states the second right L2-3 TFESI "wasn't as beneficial as the last injection" without quantifying the degree of relief. 1 The American Society of Anesthesiologists requires that additional therapeutic TFESIs should only be performed if the initial injection resulted in at least 50% pain relief for at least 2 weeks 2, 1
• No documentation exists showing increased functional activity, return to work, or reduction in pain medication use following previous injections 1
• 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

Inadequate Conservative Treatment Documentation

• There is no documentation that the patient failed 4-6 weeks of conservative therapy including physical therapy, NSAIDs, and activity modification before the initial injections 1
• The medication list is referenced but not detailed regarding non-narcotic analgesics and their failure 1
• No documentation of physical therapy attempts, duration, or outcomes 1

Missing Radiologic Correlation

• While the note mentions "severe foraminal stenosis on the right at L2-3 and on the left at L4-5," there is no attached imaging report or documentation of when this imaging was performed 1
• The American College of Physicians strongly recommends MRI evaluation demonstrating nerve root compression that correlates with clinical symptoms 1
• Advanced diagnostic imaging must have been performed within 24 months prior to the epidural injection 1

Plan Language Exclusions

The case may fall under plan exclusions:

• Maintenance Therapy Exclusion: The plan excludes "charges for rehabilitative treatment given when no further gains are clear or likely to occur" [@case documentation@]. Given that the second injection "wasn't as beneficial as the last injection," continuing injections without documented objective benefit may constitute maintenance therapy rather than therapeutic intervention
• Without documented functional improvement or pain reduction exceeding 50% for at least 2 weeks, these injections do not meet the threshold for therapeutic benefit 2, 1

Alternative Diagnostic Considerations

The clinical picture raises concerns about alternative pain generators:

• The patient has "transitional anatomy with multilevel degenerative change, scoliosis and spondylolisthesis" which suggests mechanical low back pain rather than pure radiculopathy [@case documentation@]
• Bilateral lower extremity symptoms with "worse on the right side" and pain "into the lateral thigh" may indicate L2-3 radiculopathy, but the lack of dermatomal specificity and bilateral nature raises questions about the diagnosis [@case documentation@]
• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain 1

What Would Be Required for Medical Necessity

To meet medical necessity criteria, the following documentation would be essential:

For the Third Right L2-3 TFESI:

• Quantified pain relief from the second injection (percentage and duration) showing at least 50% improvement for at least 2 weeks 2, 1
• Documentation of improved function (return to work, increased walking distance, reduced medication use) 1
• Recent MRI (within 24 months) with radiologist report confirming severe right L2-3 foraminal stenosis correlating with right lateral thigh pain 1
• Documentation of failed conservative therapy including at least 4-6 weeks of physical therapy and non-narcotic analgesics 1

For the Left L4-5 TFESI:

• This appears to be a first injection at this level, which would require different criteria [@case documentation@]
• Documentation that left lower extremity radicular pain radiates below the knee (not just "bilateral lower extremities") 1
• MRI confirmation of left L4-5 foraminal stenosis with nerve root compression 1
• Failed conservative therapy for at least 4-6 weeks including physical therapy and non-narcotic analgesics 1
• Clinical examination findings consistent with L5 radiculopathy (specific dermatomal sensory loss, motor weakness, reflex changes) 1

Surgical Consideration Context

The provider's note indicates the patient "would need three level interbody fusion with posterior instrumentation, likely with PTP" and states "we are going to try to maximize treatment with injections" before considering surgery [@case documentation@]. This raises important considerations:

• The American Society of Anesthesiologists recommends epidural steroid injections as part of a multimodal treatment regimen, not as a bridge to inevitable surgery 2
• If surgery is already being discussed as the definitive treatment for multilevel degenerative disease with scoliosis and spondylolisthesis, the role of additional injections without documented prior benefit is questionable 1
• The 2014 CDC guideline notes that interventional procedures should be performed by properly trained clinicians as part of a comprehensive pain management approach, not as a delay tactic before surgery 2

Common Pitfalls in This Case

• Assuming patient-reported "not as beneficial" equals medical necessity for repeat injection - objective criteria require at least 50% pain relief for at least 2 weeks 2, 1
• Treating bilateral multilevel degenerative disease with targeted injections - this may represent mechanical low back pain rather than true radiculopathy 1
• Proceeding with additional injections without documented response to prior injections - this exposes patients to procedural risks without established benefit 2, 1
• Failing to document conservative treatment failures - injections should not be first-line therapy 1

Recommendation

Non-certification is appropriate for both the third right L2-3 TFESI (64483) and the left L4-5 TFESI (64484). The case lacks essential documentation of prior treatment response, failed conservative therapy, and radiologic correlation. Before reconsidering these injections, the provider should document:

1. Quantified response to the second right L2-3 injection (percentage pain relief and duration)
2. Functional improvements from prior injections
3. Completion of at least 4-6 weeks of physical therapy with documented failure
4. Recent MRI report confirming bilateral foraminal stenosis correlating with symptoms
5. Specific dermatomal examination findings consistent with L2-3 and L4-5 radiculopathy

Without this documentation, proceeding with injections would not meet evidence-based medical necessity criteria and may constitute maintenance therapy excluded by the plan 2, 1.