Is a C7-T1 Interlaminar Epidural Steroid Injection (IESI) medically necessary for a patient with cervical radiculopathy (M54.12) who has failed conservative treatments, including physical therapy and analgesics, such as acetaminophen (APAP), gabapentin, and tizanidine?

Medical Necessity Determination for C7-T1 Interlaminar Cervical Epidural Steroid Injection

The C7-T1 interlaminar cervical epidural steroid injection meets medical necessity criteria for this patient with cervical radiculopathy (M54.12), as she has documented bilateral radicular symptoms with imaging confirmation of pathology, has completed conservative treatment including physical therapy and multimodal analgesics, and is receiving the injection as part of a comprehensive pain management program. 1

Criterion-by-Criterion Analysis

Criterion A: Radicular Pain Pattern - MET

• The patient demonstrates clear radicular symptoms with neck pain radiating bilaterally to shoulders and down both upper extremities with numbness and tingling 1
• For cervical radiculopathy, radicular pain is defined as pain, numbness, or weakness in the shoulder, arm, wrist, or hand, which this patient exhibits 1
• The bilateral presentation with alternating predominance does not negate the radicular nature, as the MRI demonstrates bilateral pathology (left C4-5 and C5-6 neural foraminal stenosis) 2

Criterion B: Exclusion of Intraspinal Tumor/Space-Occupying Lesion - MET

• The cervical MRI from the documented date shows diffuse arthropathy with mild annular bulging at C5-6 and C6-7, and neural foraminal stenosis at C4-5 and C5-6 1
• The imaging was performed within the required 24-month window prior to the proposed injection 1
• EMG confirms cervical involvement without evidence of polyneuropathy, ruling out alternative non-spinal etiologies 1
• Critical point: The MRI adequately excludes tumor, infection, or other space-occupying lesions as the cause of symptoms 1

Criterion C: Failed Conservative Treatment - MET

• The patient completed a full course of physical therapy as documented 1, 3
• She has been on multimodal analgesics including acetaminophen, gabapentin, low-dose naltrexone, and tizanidine 1, 3
• Previous interventions include cervical epidural (response unclear), two medial branch blocks with only short-duration relief (4-6 hours), and prior botox for migraines 1
• The duration of conservative treatment exceeds the required 4-week minimum 1, 3

Criterion D: Comprehensive Pain Management Program - MET

• The treatment plan explicitly includes multimodal medications (gabapentin, tizanidine, clonazepam) 1
• Physical therapy has been completed 1
• Psychosocial screening with PHQ-9 is documented 1
• The plan includes consideration of additional interventions (occipital nerve blocks, potential future RFA) as part of ongoing comprehensive care 1

Technical and Safety Considerations

Injection Level Selection

• The C7-T1 level is appropriate and safe for interlaminar cervical epidural injection 4
• A retrospective study of 12,168 cervical epidural injections found no correlation between spinal level and complication rates, with hundreds performed above C5-6 4
• While medication injected at C7-T1 may ascend to higher levels, inflammation at the pathologic cervical levels (C4-5, C5-6) may increase epidural pressure, causing injectate to move caudally rather than cephalad 4
• Common pitfall: The outdated belief that cervical epidurals should only be performed at C7-T1 is not evidence-based, though C7-T1 remains a safe and commonly used approach 4

Fluoroscopic Guidance Requirement

• The procedure must be performed under fluoroscopic guidance to ensure proper needle placement and minimize complications 1, 5
• Epidurography should be performed prior to therapeutic injection to confirm epidural spread 4

Expected Outcomes and Efficacy

• For acute and subacute cervical radicular pain, epidural corticosteroid administration may provide significant relief 6
• The efficacy is more limited for chronic cervical radicular pain, though this patient's alternating bilateral symptoms suggest an inflammatory component that may respond 6
• Most cases of cervical radiculopathy resolve with conservative treatment, but interventional procedures are appropriate when conservative measures fail 3
• One case series of 58 patients showed treatment success rates of 93% at 1 month, 86% at 3 months, and 72% at 6 months following cervical epidural steroid injection 7

Risk Disclosure Requirements

Shared decision-making must include discussion of potential complications 1, 5:

• Dural puncture
• Insertion-site infections
• Sensorimotor deficits
• Rare but serious complications including spinal cord injury
• The overall complication rate in large series is low, with 129 minor complications and 7 serious complications (none resulting in paralysis or death) in 12,168 procedures 4

Clinical Reasoning for This Patient

Why Delay RFA is Reasonable

• The patient's medial branch blocks provided only 4-6 hours of relief, which is diagnostically positive but suggests the pain generator may not be purely facet-mediated 1
• The bilateral alternating nature of symptoms with radicular features supports trying epidural steroid injection to address the inflammatory component from neural foraminal stenosis 6
• The patient's request to delay RFA and pursue cervical epidural steroid injection is clinically sound given the documented neural foraminal stenosis on MRI 2, 1

Addressing the Bilateral Nature

• The MRI shows left-sided neural foraminal stenosis (C4-5 and C5-6), but the patient reports bilateral symptoms that alternate 2
• The right-sided medial branch blocks provided temporary relief, suggesting a component of facet-mediated pain 1
• An interlaminar epidural approach at C7-T1 allows for bilateral medication distribution, which is appropriate for this patient's bilateral symptomatology 4

Final Determination

MEDICALLY NECESSARY - All four criteria (a, b, c, d) are met for the C7-T1 interlaminar cervical epidural steroid injection 1. The procedure should be performed under fluoroscopic guidance with epidurography, and the patient should be counseled regarding potential complications as part of shared decision-making 1, 4.