Is a Transforaminal Epidural Steroid Injection (TFESI) Bilateral L1/2 (CPT code 64483) medically necessary for a patient with radiculopathy (M54.17, M54.16, M47.816) who has failed conservative measures?

Medical Necessity Assessment for Bilateral L1/2 Transforaminal Epidural Steroid Injection

This bilateral L1/2 TFESI does NOT meet medical necessity criteria because the patient has central disc extrusions at L1-2 without significant stenosis, lacks documented radiculopathy in the L1 distribution, and the imaging findings do not correlate with the clinical presentation of left-sided symptoms radiating to the hip and lateral leg (L5/S1 distribution, not L1/2). 1

Critical Documentation Deficiencies

Anatomic Mismatch Between Symptoms and Proposed Treatment Level

• The patient's symptoms (left hip, buttocks, groin, and lateral leg pain) correspond to L5/S1 nerve root distribution, NOT L1/2 distribution 1
• The MRI explicitly states "small central disc extrusion at L1-2 WITHOUT significant stenosis" - this finding does not meet the requirement for nerve root compression 1
• The primary pathology identified on MRI is at L4-5 (right posterolateral disc protrusion moderately narrowing right neural foramen) and L5-S1 (left-sided disc protrusion), NOT at L1-2 1
• Previous injections at L5/S1 provided 50% relief in July and 30% improvement in May, confirming L5/S1 as the pain generator, not L1/2 1

Failure to Meet Radiculopathy Criteria

• True radiculopathy requires pain radiating in a specific dermatomal distribution with objective findings - L1/2 radiculopathy would cause anterior thigh pain, NOT lateral leg pain 1, 2
• The American College of Physicians defines radicular pain as pain and/or numbness radiating below the knee in a dermatomal pattern 1
• No documentation of sensory deficits, motor weakness, or reflex changes in L1 or L2 distribution 1
• The diagnosis code M47.816 (spondylosis without myelopathy or radiculopathy, lumbar region) actually contradicts the indication for TFESI, which requires documented radiculopathy 1

Inadequate Imaging Correlation

• The American College of Physicians strongly recommends MRI evidence demonstrating nerve root compression that correlates with clinical symptoms 1
• The radiologist's interpretation explicitly states "no significant stenosis" at L1-2, failing to demonstrate the required compression 1
• Central disc extrusions without foraminal narrowing or nerve root compression do not constitute appropriate anatomic substrate for TFESI 1

Evidence-Based Requirements Not Met

Conservative Treatment Documentation Issues

• While the patient has history of physical therapy for a different condition (M25.512 - multiple joint pain), there is no documentation of 4-6 weeks of conservative treatment specifically targeting the L1/2 radiculopathy 1
• The American College of Physicians strongly recommends completing minimum 4-6 weeks of failed conservative therapy including physical therapy, NSAIDs, and activity modification before considering epidural injections 1
• Previous treatments targeted L5/S1 and left hip pathology, not L1/2 1

Guideline-Based Contraindications

• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain 1
• The Journal of Neurosurgery reports minimal evidence supporting epidural steroid injections for chronic lower-back pain without clear radiculopathy 3, 1
• The patient's presentation appears more consistent with mechanical low back pain from degenerative disease rather than true L1/2 radiculopathy 1

Alternative Pain Generators to Consider

More Likely Diagnoses

• L5/S1 radiculopathy - supported by MRI findings of left-sided disc protrusion at L5-S1 mildly narrowing left lateral recess and left neural foramen, and previous 50% relief from L5/S1 injection 1
• Hip joint pathology - patient received left hip joint injection in July with only 10% relief, but hip pathology remains in differential 1
• Sacroiliac joint dysfunction - left-sided buttock and groin pain with radiation to lateral leg can originate from SI joint 1
• L4 radiculopathy - MRI shows right posterolateral disc protrusion at L4-5 moderately narrowing right neural foramen, though symptoms are left-sided 1

Critical Safety Considerations

Risk-Benefit Analysis

• Transforaminal injections carry significant risks including spinal cord infarction, paraplegia, dural puncture, cauda equina syndrome, and sensorimotor deficits 1, 2, 4
• A case report documents complete paraplegia following thoracolumbar TFESI despite proper technique and fluoroscopic guidance 4
• Exposing the patient to these catastrophic risks without appropriate indication (no nerve root compression at target level, symptoms not matching proposed treatment level) is not justified 1

Procedural Requirements If Reconsidered

• Fluoroscopic guidance is mandatory for TFESI to ensure proper needle placement 1, 2
• Shared decision-making must include specific discussion of potential complications 1, 2
• Image guidance must confirm contrast spread along the targeted nerve root 1

Recommended Clinical Pathway

Immediate Steps

• Repeat clinical examination to precisely map dermatomal distribution of symptoms - determine if pain follows L1, L2, L4, L5, or S1 dermatome 1
• Correlate examination findings with MRI pathology - the symptomatic level should match imaging findings of nerve root compression 1
• Consider diagnostic selective nerve root block at the suspected symptomatic level (likely L5/S1 based on history) rather than therapeutic injection at non-correlating level 1

If L5/S1 Confirmed as Pain Generator

• Repeat TFESI at L5/S1 may be appropriate IF previous injection provided at least 50% relief for at least 2 weeks 1
• The American Society of Anesthesiologists requires documented benefit from initial injection before repeat therapeutic injection 1
• Patient's history shows 50% relief from July L5/S1 injection, potentially supporting repeat injection at that level 1

Comprehensive Pain Management

• Optimize multimodal treatment including physical therapy specifically targeting lumbar radiculopathy, patient education, and oral medications 1, 2
• The American College of Physicians emphasizes epidural injections must be part of comprehensive pain management program 1
• Consider evaluation by spine surgeon given chronic symptoms and progressive nature 1

Common Pitfalls in This Case

• Do not perform injections based solely on anatomic findings without clinical correlation - the presence of disc pathology on MRI does not automatically indicate that level is the pain generator 1
• Do not confuse axial back pain with radicular pain - true radiculopathy requires dermatomal radiation, not just localized spinal pain 1, 5
• Do not ignore previous treatment responses - the patient's 50% relief from L5/S1 injection strongly suggests that is the symptomatic level 1
• Do not expose patients to procedural risks without clear indication - TFESI carries risk of catastrophic neurologic injury and should only be performed when criteria are met 1, 4