Should a patient with chronic low back and buttock pain, severe bilateral foraminal narrowing at L5-S1, and failed noninvasive treatment, be approved for Epidural Steroid Injection (ESI) benefit coverage?

Coverage Decision: DENY

Based on the most recent and highest quality guidelines, this epidural steroid injection request should be DENIED because the patient lacks documented radiculopathy—the essential criterion for medical necessity. 1, 2

Critical Missing Criteria for Medical Necessity

Absence of Radiculopathy

• The patient does not meet the fundamental requirement for ESI: radicular pain radiating below the knee. 1, 2
• The clinical documentation explicitly states "Denies radiation of pain" and describes pain as "more central in low back and buttock." 1
• Radiculopathy is specifically defined as pain and/or numbness radiating below the knee—not just back or buttock pain. 1, 3
• The straight leg raise test (SLT) was negative, and there are no documented sensory changes, motor weakness, or reflex changes. 1
• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain. 1, 2

Contradictory Physical Examination Findings

• All sacroiliac joint provocation tests (Faber's, Gaenslen's, thigh thrust) were negative, yet the patient has buttock pain—this suggests the pain generator has not been adequately identified. 1
• The patient demonstrates full range of motion, non-antalgic gait, and is neurologically intact—findings inconsistent with disabling radiculopathy requiring intervention. 1

Why This Matters for Morbidity and Mortality

Risk Without Benefit

• Transforaminal epidural steroid injections carry significant risks including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, retinal complications, and rare catastrophic complications including paralysis and death. 1, 2
• The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain without radiculopathy, stating "all or nearly all well-informed people would likely not want such interventions." 1
• Exposing this patient to these risks without meeting the evidence-based indication for radicular pain is not medically justified. 1

Evidence-Based Guidelines Are Clear

• The American Society of Anesthesiologists strongly recommends epidural steroid injections specifically for patients with radicular pain or radiculopathy—NOT for axial back pain from foraminal stenosis alone. 1, 2
• The American College of Occupational and Environmental Medicine guideline explicitly recommends AGAINST lumbar epidural injections for spinal stenosis in the absence of significant radicular symptoms. 1
• Multiple high-quality guidelines from 2023-2025 consistently state that ESI is indicated for radiculopathy, not for mechanical back pain. 4, 1, 2

What This Patient Actually Needs

Alternative Diagnostic Workup

• The pain generator has not been adequately identified. The patient has severe bilateral foraminal narrowing at L5-S1 on imaging, but this does not correlate with clinical symptoms (no radiculopathy). 1, 2
• Consider formal evaluation for sacroiliac joint dysfunction, facet-mediated pain, or hip pathology as alternative pain sources. 1
• The British Pain Society emphasizes that imaging findings must correlate with clinical presentation—anatomic findings alone do not justify intervention. 1

Appropriate Conservative Management

• The patient is already seeing a chiropractor for manipulation and exercises, which is appropriate. 1
• Continue optimization of multimodal conservative therapy including physical therapy, NSAIDs, and activity modification. 1, 2
• The goal should be identifying the actual pain generator rather than proceeding with an intervention that does not match the clinical presentation. 1

Common Pitfall Being Made Here

This case represents a classic error: treating imaging findings rather than clinical symptoms. 1, 2

• Severe foraminal stenosis on MRI does not automatically warrant ESI if the patient lacks radicular symptoms. 1, 2
• The provider appears to be requesting ESI based on anatomic findings (foraminal narrowing) rather than the required clinical syndrome (radiculopathy with leg pain below the knee). 1, 2
• This approach exposes the patient to procedural risks without evidence-based indication and may delay identification of the true pain source. 1

Documentation Requirements Not Met

• No documentation of pain radiating below the knee. 1, 3
• No positive straight leg raise test. 1
• No dermatomal sensory changes. 1
• No motor weakness in a nerve root distribution. 1
• No reflex asymmetry. 1
• Without these clinical findings of radiculopathy, ESI is not medically necessary regardless of imaging findings. 1, 2