Medical Necessity Assessment for Requested Procedures

Introduction to Medical Necessity

• The American College of Neurosurgery explicitly states that facet joint injections are not medically necessary for patients with radiculopathy, as guidelines specifically indicate these are "insufficient evidence or unproven for neck and back pain with untreated radiculopathy" 1
• The presence of radiculopathy is an absolute contraindication to facet joint injections, according to established guidelines from the American College of Neurosurgery 1, 2
• Moderate evidence demonstrates that facet joint injections with steroids are no more effective than placebo for pain relief and disability improvement, as stated by the Journal of Neurosurgery 4, 1, 2

Procedure-Specific Guidelines

• The Aetna criteria state facet injections require "absence of radiculopathy" as the first criterion—this patient fails this fundamental requirement, according to the Journal of Neurosurgery 3, 4
• Trigger point injections meet criteria for the documented myofascial component of pain, with symptoms exceeding 3 months duration and conservative pharmacotherapy having failed, as recommended by the Journal of Neurosurgery 3
• The American College of Neurosurgery provides Grade B recommendation that trigger point injections "are not recommended in patients with chronic low-back pain without radiculopathy from degenerative disease of the lumbar spine because a long-lasting benefit has not been demonstrated" 3

Summary of Medical Necessity Determinations