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Maturus Software Technologies Corporation DBA Matutech, Inc

881 Rock Street New Braunfels, TX 78130

Phone: 800-929-9078 Fax: 800-570-9544

Notice of Independent Review Decision August 25, 2017

IRO CASE #:

DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE: Left selective nerve root block at C5-C6

A DESCRIPTION OF THE QUALIFICATIONS FOR EACH PHYSICIAN OR OTHER HEALTH CARE PROVIDER WHO REVIEWED THE DECISION:

American Board of Physical Medicine & Rehabilitation American Board of Pain Medicine

REVIEW OUTCOME: Upon independent review, the reviewer finds that the previous adverse determination/adverse determinations should be:

X Upheld (Agree) Medical documentation does not support the medical necessity of the health care services in dispute.

PATIENT CLINICAL HISTORY [SUMMARY]: The patient is a XXXX who works as a XXXX. On XXX, the patient while XXX, bumped his head, and had hard hit on and jarred his neck. He was XXXX and denied loss of consciousness (LOC) or visual changes. On XXX, the patient was evaluated at XXX. The patient complained of moderate back pain caused by XXXX. He reported XXX repetitively at work for the last XXXX. His left arm was not working correctly. He had limited ROM of the neck. The pain was located at the left scapular area and was radiating into the left shoulder and arm. He was not working. On examination, there was limited range of motion (ROM) of the neck secondary to pain. There was no midline tenderness or deformity. The patient was neurologically intact. There was T1-T3 paraspinal and infrascapular tenderness. The x-rays of the chest showed no acute cardiopulmonary abnormality. A magnetic resonance imaging (MRI) of the cervical spine showed at C5-C6, mild left-sided canal stenosis. There was mild-to-moderate left greater than right neural foraminal narrowing. Other lesser spondylotic changes without significant canal stenosis or neural foraminal narrowing at the remaining cervical levels were noted. No marrow edema or ligamentous edema noted. The diagnosis was cervical radiculopathy. On discharge, his condition was stable. The discharge medications included Ibuprofen and Flexeril. On XXX, XXX, M.D., evaluated the patient in an initial evaluation at XXX for the complaints of neck pain radiating down the center of the back and left arm. The patient was injured on XXX, while XXX, bumped his head onto and hit the top of the head. He was wearing XXXX. He denied loss of consciousness (LOC) and visual changes. After XXXX later, he developed neck pain mostly on the left side. On the next day, he felt pain at the mid back area on the left. On XXX, he barely could use the left arm because of numbness and weakness. He went to XXXX on XXX, and MRI of the cervical spine was done. He was prescribed Medrol Dosepak, ibuprofen, and Flexeril. He developed nausea and abdominal pain after taking Ibuprofen. Currently, he complained of constant pain over the left upper back, left arm numbness and pain radiating to the upper arm and forearm. He also reported left arm weakness. The pain was worse with torso twisting. The neck pain

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was worse with extension and on rotating the head on the left side. He also reported left arm pain while XXXX. He also reported he was XXXX repetitively almost everyday up to XXXX. He currently rated his pain at 8/10. The examination of the left shoulder showed he had pain with flexion, abduction, and internal and external rotation. The flexion and abduction were 4/5 on the left side. He had a painful equivocal arc, equivocal Apley’s and Hawkins test. The examination of the cervical spine showed tenderness over the left trapezius muscle, but not the cervical spine and left and right paraspinal and right trapezius muscle area. There was left-sided muscle spasm. The active range of motion (ROM) on extension was restricted and painful. Bilateral side bending of his neck was painful. There was equivocal Spurling’s maneuver. The examination of the thoracic spine showed tenderness over the thoracic spine (at T4, T5, T6, and T7 levels), left paraspinal (at T4, T5, T6, and T7 levels) and tenderness in the left rhomboid muscle. He also had muscle spasm on the left side. There was pain on flexion. The diagnoses were cervical radiculopathy at the C5 level, degenerative arthropathy of the spinal facet joint, and strain of thoracic region, left shoulder and neck muscle. The patient was referred to an Orthopedic and was recommended to undergo PT for three times in a week for two weeks. Aleve and Tramadol were prescribed. He was placed on restricted work duty. From XXX, through XXXX, the patient underwent six PT sessions at XX. The patient complained of pain in the cervical spine, thoracic spine and left shoulder region. The diagnosis was cervical radiculopathy. Treatment modalities included therapeutic exercises and activities, neuromuscular re-education and manual therapy. On XXX, XXXX, M.D., evaluated the patient for a follow-up on the neck, left upper back and left arm pain. The patient reported no change in his symptoms. He reported left arm numbness and weakness was not better. He still complained of neck and upper back pain worse with head bending backwards and left arm shooting pain. The pain was located in the left posterior neck region. He described the pain as constant, moderate, dull and aching in nature. The associated symptoms included neck muscle spasm, stiffness, upper extremity paresthesias and weakness. The pain was exacerbated by neck and arm movement and relieved with nonsteroidal antiinflammatory drugs (NSAIDs). On examination, the left shoulder had painful flexion, abduction and adduction. There was tenderness in the left forearm (radial, dorsal and proximal), cervical spine left paraspinal muscles (C4 and C5), left trapezius and thoracic spine (T3, T4, T5 and T6) and left rhomboid muscles. The cervical spine ROM was limited and painful with flexion to 20 degrees, right rotation to 20 degrees and left rotation to 45 degrees. The flexion was painful at thoracic spine. There was diminished light to touch sensation of the left outer upper arm (C5), left radial forearm, thumb and index finger. Deep tendon reflexes (DTRs) were 1+ at bilateral biceps, triceps and brachioradialis. The diagnoses were cervical radiculopathy at C5, degenerative arthropathy of spinal facet joint, strain of the left shoulder and acute neck muscles. Tramadol was prescribed. Per Utilization Review dated XXXX, the requested service for PT was approved. On XXX, XXXX, D.O., evaluated the patient in an initial office visit at XXXX for neck and back pain. The patient reported 75% neck pain and 25% arm pain. He complained of left paraspinous neck pain radiating to the left scapula. He also complained of tingling and numbness in the left arm in the distribution of C6. He had been evaluated by a physical therapist but had not attended a session yet. He noticed some difficulty with fine motor actions. He rated his pain at 7-8/10. The patient also reported left arm and finger pain and numbness. He rated his pain at 8/10. He had past surgical history of bilateral knee, shoulder and carpal tunnel surgery. The examination of the cervical spine showed increased pain with extension and limited ROM with extension. The muscle strength was 5/5. There was positive Tinel’s sign noted at elbow and wrist on the left side. There was amputated left thumb at distal interphalangeal joint (DIP). X rays of the cervical spine were reviewed which showed normal lordotic curve of the cervical spine and disc spaces appeared to be adequate. MRI of the cervical spine was reviewed which showed mild disc osteophytic bridging eccentric to the left with severe left greater than right neuroforaminal narrowing at C5-C6 as well as flattening of the ventral cord without cord edema. The diagnoses were cervical radiculopathy and neck pain. Dr. XX recommended cervical epidural steroid injection (ESI) at the C5-C6 level on the left side. Mobic was prescribed instead of the Advil. On XXXXX, the patient underwent x rays of the cervical spine. The study revealed slight C5-C6 kyphosis in the neutral position, partially reduced on the extension view. There was minimal loss of the anterior C5-C6 disc height. There was slight C3-C4 and C4-C5 anterolisthesis appearing on the flexion view, reducing the extension view, suggesting facet joint capsule laxity. Tiny anterior endplate osteophyte at every level consistent with early degenerative disc disease (DDD) were

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noted; otherwise, normal intervertebral disc heights noted. There were normal vertebral body heights, and no evidence of fracture or other bone lesion noted. On XXXX, Dr. XXXXX evaluated the patient for continuing back and left arm pain. The patient complained of left volar elbow pain, on and off whole hand numbness and pain in the middle of the back and neck. The pain was worse with neck extension and lasted for whole day. The pain interfered with sleep. On examination, left shoulder ROM was painful in forward flexion, extension, abduction and adduction. There was pain at posterior upper back with arm movement. The flexion and abduction were 4/5 on the left. The cervical spine showed tenderness over the cervical spine (C4 and C5), decreased and painful ROM and positive Spurling’s test. There was tenderness at the left-sided thoracic spine and left paraspinal muscles (T4, T5, T6 and T7) with painful flexion. There was diminished light touch sensation at the left outer upper arm (C5), left radial forearm, thumb and index finger (C6). The diagnoses were C5 cervical radiculopathy, degenerative arthropathy of the spinal facet joint, strain of the left shoulder and acute strain of the neck muscles. Methylprednisolone and Tylenol were prescribed, and the patient was placed on a modified duty. On XXX, XXX, M.D., evaluated the patient for neck and left shoulder pain. The symptoms remained unchanged. He reported worsening headache, neck and back pain and constant numbness in the left arm. He rated pain at 7-8/10. Dr. XXXX placed the patient on a modified duty. On XXX, Dr. XXXX evaluated the patient in a follow-up visit. The patient reported 75% neck pain and midline occipital headaches, as well as 25% left arm pain in the C6 distribution. He rated his pain at 7/10. He had noticed some difficulty with fine motor actions. He also reported numbness, tingling, and weakness in the left arm. MRI of the cervical spine reviewed which showed disc herniation/osteophyte complex at C5-C6 on the left causing severe compression on the left-sided C6 nerve root. The examination of the cervical spine showed left paraspinous neck pain and increased pain with extension. The muscle strength was 5/5. There was positive Spurling maneuver test noted on the left side. The diagnoses were herniated nucleus populous (HNP) and cervical radiculopathy. The patient was referred to Dr. XXXX for a cervical ESI at C5-C6 on the left, as well as for a possible occipital nerve root injections. On XXX, Dr. XXX evaluated the patient for a follow-up visit. The patient reported severe neck pain. He reported none of the medications were helpful for his pain. He had constant tingling and numbness. He had tried exercises, but it resulted in a lot of pain. On examination, increased lordosis was noted. Tenderness was noted at the C3-T2 left paraspinal and left trapezius muscles. The cervical ROM was painful in extension and left-sided bending at 20 degrees and left rotation at 25 degrees. The diagnoses were cervical radiculopathy at C5 and strain of the neck muscle. No medications were prescribed. Modified duty was continued. On XXX, XXXX, D.O., evaluated the patient in an initial office visit. The patient reported pain radiating from the left neck greater than the shoulder area. The pain was described as sharp. The pain was radiating down the anterior and lateral arm to the hand. He continued to have left upper extremity weakness secondary to pain. His symptoms were mostly aggravated with neck rotation to the left side. He had Improvement with sitting in a recliner. He had tried multiple different antiinflammatories, which included Mobic, Aleve, and Medrol Dosepak with minimal improvement. He discontinued tramadol secondary to nausea. He also reported headaches. The past surgical history was positive for right rotator cuff repair, bilateral hand carpal tunnel release, and knee surgery. The examination of the cervical spine showed tenderness over the left cervical area. There was increased pain with extension, limited ROM with flexion and extension and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased over the lateral and posterior aspect of the upper arm. There was positive Spurling maneuver. The diagnoses were cervical radiculopathy and neck pain. Aspirin, Aleve, and gabapentin were prescribed. Dr. XXXX recommended left-sided C5-C6 transforaminal ESI for diagnostic and therapeutic benefits and also stated that this procedure was approved under ODG guidelines and was medically necessary. He was advised to continue home exercise program (HEP) to improve cervical ROM, core, strength, and flexibility. Per Utilization Review dated XXXX, the request for left C5-C6 transforaminal injection was denied. The criteria used for the denial was ODG Neck and Upper Back (updated XXXX), Epidural steroid injection (ESI). The rationale was “Not recommended based on recent evidence, given the serious risks of this procedure injection (ESI) in the cervical region and

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the lack of quality evidence for sustained benefit.” The criteria for the use of therapeutic epidural steroid injections were: “(I) ESIs are not recommended higher than the C6-C7 level; (II) Cervical inter laminar ESI is not recommended. (III) Particulate steroids should not be used. (Benzon, 2015)” Criteria for the use of diagnostic Epidural steroid injections: “If used for diagnostic purposes, a maximum of two injections should be performed. A second block is not recommended if there is inadequate response to the first block. Diagnostic blocks should be at an interval of at least one to two weeks between injections.” On XXX, Dr. XXXX evaluated the patient for a follow-up visit. The patient reported headache and neck pain. He was going to get a cervical injection from pain management but it was denied. On examination, guarding with right bending was noted. Severe restriction was noted in the rotation and side-bending bilaterally, more on the left. There was tenderness over the cervical paraspinal muscles and left-sided muscle spasm. The diagnoses were cervical radiculopathy at C5 and strain of muscles. The patient was continued on the light duty. On XXX, Dr. XXXX, evaluated the patient in a follow-up visit. The patient reported significant stiffness in the neck, left arm pain, and weakness. He currently reported left-sided neck and shoulder pain and numbness that radiated down the anterior and lateral arm to the hand. The pain was sharp, dull, and aching. He also reported left upper extremity weakness secondary to pain and headaches. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased of the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test noted. Dr. XXXX attempted to schedule and complete a left C5-C6 transforaminal ESI for the diagnostic and therapeutic benefit, but this was denied through workmen's compensation due to their policy not approving ESIs above the C6-C7 area. The treatment recommendations included increasing gabapentin dose, continuing HEP, and referral back to Dr. XXXX for possible surgical option as cervical ESI was denied by worker’s compensation. On XXXX, Dr. XXXX evaluated the patient in a follow up visit. The patient was unable to get ESI at C5-C6 on the left. The procedure was denied by insurance citing that ESIs were no longer recommended in the cervical spine due to the use of particulate steroids. At the point, he had seven sessions of physical therapy (PT) with no relief. He reported some difficulty with the fine motor control. He rated his pain at 7/10 with 75% neck pain and midline and occipital headaches as well as 25% left arm pain in the C6 distribution, where he also had numbness in the arm. The examination of the cervical spine showed increased pain on flexion and extension with limited ROM. Muscle strength was 5/5. The sensation was decreased over the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver. Dr. XXXX recommended diagnostic nerve root block at C5-C6 on the left and electromyogram (EMG). On XXXX, Dr. XXXX evaluated the patient for a follow-up visit. The patient continued to have neck pain, headache and left shoulder to finger numbness. He was taking gabapentin. On examination, loss of normal lordosis was noted. There was tenderness at the C3-T2 and bilateral paraspinals and bilateral trapezius muscles. The flexion was painful, extension was at 10 degrees, right rotation was 35 degrees and left rotation was at 30 degrees and painful. There was positive Spurling’s maneuver. The diagnoses were cervical radiculopathy, strain of neck and thoracic region and acute strain of the neck muscles. Methocarbamol was prescribed. On XXXX, a Utilization Review indicated the request for an EMG study was approved. On XXXX, XXXX, M.D., saw the patient in an office visit for electrodiagnostic studies. The patient had neck pain, left upper extremity pain, and numbness in the fingers of the left hand. He continued to have left arm pain at night with numbness in the thumb and index fingers. The patient reported he would have neck pain when he rotates his neck toward the right or the left. On examination, neck rotation toward the left produced sharp pain radiating toward the left upper extremity. ROM of the shoulder was within normal limits. Manual muscle strength testing of the upper extremities revealed weakness on left wrist extension. Bicep reflexes were 2+ bilaterally. Triceps reflex was I+ bilaterally. Dr. XXXX performed EMG/NCS study which showed large amplitude motor unit action potentials in the left triceps and anconeus muscles were consistent with a diagnosis of injury to the muscles or to their nerve supply, usually the C7 nerve root. The imaging study was reported to be consistent with C6 nerve root injury. The median nerve distal latencies were prolonged, consistent with the history of carpal tunnel syndrome. Tardy ulnar nerve across the left elbow was consistent with a diagnosis of

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compression injury at or near the elbow. On XXXX, XXXX, M.D., completed a Peer Review and opined that the diagnoses that produced by the onetime work incident that occurred on XXXX, was cervical sprain/strain based on the mechanism of injury, symptoms, exam findings and diagnostic findings. The onetime alleged work incident on XXXX, produced a cervical sprain/strain with no new acute structural damage to the cervical spine, and therefore no aggravation or acceleration of the preexisting disease process was noted in the multiple levels of the cervical spine, most advanced at CS-6. Any diagnosis other than a cervical sprain/strain was not produced, accelerated or aggravated by a one time alleged work incident. The ODG would support an over the counter analgesic, occasional use of an over the counter nonsteroidal and a home exercise program. The ODG would not support additional diagnostics, injections, surgery, FCEs, work hardening/conditioning, or prescription medications as related to the cervical sprain/strain. The patient’s current medications included methocarbamol. On XXXX, Dr. XXXX evaluated the patient for a follow-up visit. The patient’s condition remained the same. He had weakness and tingling in his arms. The pain was rated at 8/10. He had the NCT which showed some damage at the C7. He also had weakness in the left hand. On exam, there was a loss of normal lordosis, tenderness at C3-T1 bilateral paraspinal muscles and limited ROM in all planes, but more on the left and right side rotation. There was weakness with left side grip when compared to the right. The diagnoses were acute cervical radiculopathy and strain of neck muscles. No medications were prescribed at this time and continued modified duty. On XXXX, Dr. XXXX evaluated the patient in a follow up visit. The patient rated his pain at 7/10. He reported 75% neck pain, where his pain was in the midline spine region, as well as having occipital headaches. He also had 25% left arm pain in the C6 distribution that was a combination of pain and numbness. EMG/NCS was reviewed. He did have a peer review on XXXX, by Dr. XXXX, cervical spine injection requests had been denied. He had been notified of an upcoming designated doctor's exam (DDE) for maximum medical improvement/impairment rating (MMI/IR) as well as extent of injury. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased over the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test. The diagnoses were sprain of ligaments of the cervical spine, cervical radiculopathy, and neck pain. The recommendations included follow-up after DDE. On XXXX, XXXX, D.C., performed Designated Doctor’s Examination (DDE) and opined that the patient’s compensable injury included the diagnoses of cervical strain/sprain, aggravation and worsening of cervical spondylosis and disc herniation at C5-C6. The claimant had not reached MMI and estimated date of MMI was on XXXX, as the date of MMI. The patient was eligible to receive treatment to reduce the compression or pressure against the nerve root which was causing neurological deficits into the left arm. This might include epidural steroid injection and/or surgical intervention. On XXX, Dr. XXXX evaluated the patient for persistent neck pain, tingling/numbness and weakness in the left arm. On exam, there was tenderness over C3-T1 cervical spine and C3-T1 left paraspinal muscles, limited left rotation and side-bending with pain. The diagnoses were acute cervical radiculopathy at C5 and strain of the neck muscles. the Patient was advised to refer Dr. XXXX for an injection and no medications were prescribed. On XXXX, the patient was evaluated by Dr. XXXX in a follow up visit. The patient was having 75% neck pain and 25% left arm pain. He did have a DDE for MMI as well as extent of injury by XXXX, D.C. She did agree with the diagnosis of cervical radiculopathy, aggravation of underlying C5 to C6, and did not agree with cervical disc degeneration or cervical spondylolysis arthropathy. She did recommend expected MMI of XXX, and that he was eligible to receive treatment to reduce compression or pressure against the nerve root, which was causing neurological deficits into the left arm, including ESI or surgical intervention. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased over the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test. The recommendation included ESI at C5-C6 level. Per correspondence dated XXXX, the patient was scheduled for a Post-Designated Doctor Required Medical Examination

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on XXXX. On XXXX, Dr. XXXXX evaluated the patient for persistent neck and left shoulder pain. The patient reported no change in his condition. He still reported neck pain during sleeping, shoulder aching pain and numbness. He was taking Aleve. On exam, decreased lordosis, tenderness at C3-T2 left paraspinal muscle and severe restriction on the left side rotation and side-bending was noted. The diagnoses were acute cervical radiculopathy and acute strain of neck muscle. Modified duty was continued. On XXX, Dr. XXXX evaluated the patient in a follow up visit. The patient continued to have left-sided neck pain with extension and rotation greater than the right. He had recently completed a DDE on XXXX that stated he had not reached MMI and that he was eligible to receive treatment to reduce the compression or pressure against the nerve root, which was causing neurological deficits into the left arm. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased over the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test. He was scheduled for left-sided C5-C6 transforaminal ESI. On XXXX, Post-Designated Doctor’s Required Medical Examination by XXX, M.D. was performed. Dr. XXXX opined that: Scenario 1: The extent of injury would be the sprain/strain and aggravation of pre-existing degenerative findings with non-verifiable radicular complaints. Dr. XXX agreed with the designated doctor that if the sprain/strain that was accepted then the sprains/strains ordinarily healed within six to eight weeks even without treatment. The patient did have conservative treatment and would have been at the maximum medical benefit by XXXX, and agreed with the impairment rating of category 2 at 5% because the patient had the non-verifiable radicular complaints. He could not be qualified for category 3 because his reflexes were equal and symmetrical and there was no atrophy of 2 cm or more. So, the patient would probably be a category 2 of 5% whole person impairment. Scenario #2: If accepted sprain/strain and the other diagnoses of cervical spondylosis, facet joint arthropathy, canal stenosis, aggravation and worsening to the cervical spondylosis, questionable disk herniation at CS-C6, then the patient would not be at MMI and should be at MMI by XXXXX, after epidural steroid injections. Dr. XXXX did not believe that the patient was in any way a surgical candidate. Scenario 3: Dr. XXXX opined and agreed with designated doctor, with all the findings that were present, the rereads of the EMG, the clinical findings, the clinical findings that did not correlate with MRI findings and with the history of the pain and numbness in the arm that comes and goes, the patient was not at MMI and he would be a candidate for epidural steroid injections. Dr. XXXX opined that the patient had undergone epidural steroid injections, there was really nothing further to offer the patient, and he would be at XXXX at that time. The patient could return to work in the sedentary and light category. He should be doing XXX, and particularly any lifting above his shoulder level. He basically could do any job in the sedentary and light category. Per a Utilization Review dated XXXX, the request for left transforaminal ESI at C5-C6 was denied. The criteria used for the denial was ODG Neck and Upper Back (updated XXXX), Epidural steroid injection (ESI). The rationale for denial was “Not recommended based on recent evidence, given the serious risks of this procedure in the cervical region andthe lack of quality evidence for sustained benefit. This treatment had been recommended as an option for treatment of radicular pain (defined as pain in dermatomal distribution with corroborative findings of radiculopathy) with specific criteria for use below”. The criteria for the use of therapeutic epidural steroid injections was: “(1) Radiculopathy must be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing. (2) Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle relaxants). (3) Injections should be performed using fluoroscopy (live X-ray) for guidance. (4) No more than two nerve root levels should be injected using transforaminal blocks. (5) No more than one interlaminar level should be injected at one session. (6) In the therapeutic phase repeat blocks should only be offered if there is at least 50% pain relief for six to eight weeks, with a general recommendation of no more than 4 blocks per region per year. (7) Repeat injections should be based on continued objective documented pain and function response. (8) Current research does not support the series-of three injections in either the diagnostic or therapeutic phase. We recommend no more than 2 ESI injections. (9) It is currently not recommended to perform epidural blocks on the same day of treatment as facet blocks or stellate ganglion blocks or sympathetic blocks or trigger point injections as this may lead to improper diagnosis or unnecessary treatment. (10) Cervical and lumbar epidural steroid injection should not be performed on the same day (11) Additional criteria based on evidence of risk: (i) ESIs are not

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recommended higher than the C6-7 level (ii) Cervical interlaminar ESI is not recommended; (iii) Particulate steroids should not be used. (Benzon, 2015). The Criteria for the use of diagnostic Epidural steroid injections: (1) To help to evaluate a pain generator when physical signs and symptoms differ from that found on imaging studies (2) To help to determine pain generators when there is evidence of multilevel nerve root compression (3) To help to determine pain generators when clinical findings are suggestive of radiculopathy (e.g., dermatomal distribution, and imaging studies have suggestive cause for symptoms but are inconclusive (4) To help to identify the origin of pain in patients who have had previous spinal surgery.” On XXXX, a second opinion was rendered on the MRI of the cervical spine dated XXXX by XXXX, M.D. The impression was mild disc degenerative more prominent at C5-C6 and mild reversal of the cervical lordosis centered at C4-C5. On XXXX, an EMG/NCV was reread by XXX, M.D. The left upper extremity motor and sensory nerve conduction data points were valid and technically sound and correlate with corresponding wave forms. The needle EMG exam of the left upper extremity was adequate in terms of choice and number of muscles studied. The summary of the findings was accurate. The diagnostic conclusions were accurate and valid based on the EMG/NCV data points provided. This was an abnormal EMG/NCV study of the left upper extremity with electrodiagnostic evidence supporting the diagnoses rendered. The cervical spine MRI was also reviewed which showed moderate loss of disc height at CS-C6, moderate posterior spondylosis with bilateral uncovertebral spurring most prominent on the left without focal protrusion was noted. There was a Spur disc complex abutting the left aspect of the cervical cord without compression, moderate left and mild right foraminal narrowing, minimal posterior spondylosis with bilateral uncovertebral spurring at C6-C7 and C4-C5 without associated protrusion. On XXXX, Dr. XXXX evaluated the patient for persistent neck and shoulder pain. The patient’s condition was noted to be getting worse. The patient reported weakness in the left arm and tingling/numbness in the fingers. On exam, there was tenderness over C3-T2 left paraspinal muscles and left trapezius muscles and limited ROM of the cervical spine with left side rotation and side-bending. The diagnoses were acute strain of the neck muscles and cervical radiculopathy at C5. Dr. XXX placed the patient on a light duty. On XXXX, Dr. XXXX evaluated the patient in a follow up visit. The patient continued to have neck and left arm pain. He rated his pain at 8/10 with 75% neck pain and 25% left arm pain. He did have a DDE performed on XXXX, by. Dr. XX XXXX. Dr. XXXX opined that the patient was taking over-the-counter (OTC) antiinflammatories which would not work for him very well. Dr. XXXX also opined that the injury was preexisting and degenerative. However, the patient was injured when XXXX, compressing his neck. Therefore, the aggravation of pain due to neural foraminal narrowing at C5 to C6 was a direct result of his Injury, and as the patient was not at MMI, the patient could proceed with ESI. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased on the lateral and posterior upper arm, left index finger and thumb. There was positive Spurling maneuver test and Tinel’s sign noted at elbow and wrist on the left side. Ibuprofen was prescribed. Dr. XXXX recommended another DDE examination by board certified spine surgeon. On XXXX, Dr. XXXX evaluated the patient for persistent neck and left shoulder pain. The patient underwent DDE exam which documented he was a candidate for cervical epidural, but the injection was not approved. He reported sharp pain in the left arm. He was not working. On exam, there was tenderness over C3-T2 left paraspinal muscle and left trapezius muscles and limited extension and left side rotation. The diagnoses were cervical radiculopathy at C5 and acute strain of the neck muscles. No medications were prescribed at this time. The patient was allowed to return to a modified work. On XXX, the patient was evaluated by Dr. XXXX in a follow up visit. The patient continued to have pain in the neck and arm region. He rated his pain at 8/10, where he did have about 75% neck pain and 25% left lateral arm symptoms that he described as numbness and tingling. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased on the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test and Tinel’s sign noted at elbow and wrist on the left side. The request for the DDE to be performed by a spine surgeon had been declined by the patient’s adjuster, and they also believed that the patient was at MMI on XXXX, per previous DDE. A

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request for ESI was denied based on the reason that the study showed adverse effects of the steroids in the cervical spine. Dr. XXX recommended diagnostic nerve block without steroid to be performed by Dr. XXX at C5-C6 on the left and then further recommendations depending on how patient respond to the diagnostic nerve block. On XXX, Dr. XXX evaluated the patient in a follow-up visit. The patient continued to have left-sided neck pain, shoulder pain, and arm pain that radiated down the left lateral arm to his hand. His pain was described as of aching, numbness, tingling, and stabbing quality. Most of his symptoms were aggravated with neck extension and neck rotation to the left side greater than the right. He currently was taking OTC Aleve once a week with mild benefit. The examination of the cervical spine showed increased pain with extension, limited ROM with flexion and extension, and increased pain with left rotation. Muscle strength was 5/5. The sensation was decreased on the lateral and posterior upper arm, left index finger, and thumb. There was positive Spurling maneuver test and Tinel’s sign noted at elbow and wrist on the left side. The diagnoses were cervical radiculopathy, cervical HNP, and neck pain. The treatment recommendations included C5-C6 selective nerve root block and continuation of aspirin and naproxen. On XXXX, XX XXXX, M.D., completed utilization review. The request of left selective nerve root block (SNRB) at C5-C6 was uncertified on the basis of following rationale: “In this case, the claimant suffered an XXX injury, and has complaints of neck pain with radiation into the upper extremity, and the provider is requesting a C5-C6 selective nerve block. Per ODG Neck and Upper Back Chapter Epidural steroid injection (ESI), "Not recommended based on recent evidence, given the serious risks of this procedure in the cervical region, and the lack of quality evidence for sustained benefit." There is no documentation of exceptional factors to support an epidural steroid injection outside of current evidence-based guideline recommendations which specifically indicate lack of support for this procedure especially above the level of C6-C7. The request for a left selective NRB C5-C6 is not medically necessary at this time.” Per Initial utilization review determination notice dated XXXX, the request of left selective nerve root block (SNRB) at C5-C6 was denied. On XXX, Dr. XXXX evaluated the patient in a follow-up visit. The patient continued to have left-sided neck pain, shoulder pain, and arm pain. Cervical examination showed he had tenderness to palpation along the left middle and lower cervical paraspinal muscles. He had increased pain with cervical flexion, limited ROM with cervical flexion, increased pain with cervical extension, limited ROM with cervical extension, and increased pain with rotation to the left side. Muscle strength in bilateral upper extremities was 5/5, which included shoulder abduction, elbow flexion, elbow extension, wrist extension, and grip strength except left-sided biceps which was 4+/5 and left-sided triceps was 4+/5. There was decreased sensation along the left lateral and posterior upper arm, left index finger, and left thumb. He had positive Spurling maneuver on the left-side. Deep tendon reflexes were 1/4 on bilateral biceps, triceps, and brachioradialis. On gait evaluation, the patient had a nonantalgic gait and he used no assistive device for ambulation. Dr. XXXX stated the patient was the ideal candidate for a left sided C5-C6 selective nerve root block. Per a correspondence dated XXXX, a request for reconsideration was applied. On XXXX, XX XXXX, M.D. completed reconsideration reveiw. The request of left selective nerve root block at C5-C6 was uncertified on the basis of following rationale: “The ODG Treatment Index does not address diagnostic cervical selective nerve root blocks, which are commonly known of as transforaminal epidural injection. Cervical epidural injections, commonly including the injection of a corticosteroid, are not recommended by the ODG Treatment Index based on the relatively high incidence of serious or catastrophic neurological injuries. Although some of these are due to inadvertent injection of particulate steroid material into an artery feeding the cervical cord, a second mechanism is direct mechanical injury to the cord from the injection needle. Furthermore, there is no evidence diagnostic transforaminal steroid injections are of any practical diagnostic use. Although they can, in theory, help confirm the nerve root level(s) responsible for the pain and, many decades ago were sometimes used for this purpose, modern imaging such as MRis are much more accurate in guiding surgery. Therefore, based on the lack of evidence of their usefulness as well as the unreasonably high risk of injury posed by transforaminal injection, they cannot be considered to be medically necessary.” Per Reconsideration notification dated XXXX, the request of left selective nerve root block (SNRB) at C5-C6 was denied.

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On XXXX, correspondence from XX XXXX indicated the patient appealed for his denied request.

ANALYSIS AND EXPLANATION OF THE DECISION INCLUDE CLINICAL BASIS, FINDINGS, AND CONCLUSIONS USED TO SUPPORT THE DECISION:

Epidural Steroid Injection (ESI) – Cervical Per the ODG: Recommendation Not recommended based on recent evidence, given the serious risks of this procedure in the cervical region, and the lack of quality evidence for sustained benefit. These had been recommended as an option for treatment of radicular pain (defined as pain in dermatomal distribution with corroborative findings of radiculopathy), with specific criteria for use below. In a previous Cochrane review, there was only one study that reported improvement in pain and function at four weeks and also one year in individuals with radiating chronic neck pain. (Peloso-Cochrane, 2006) (Peloso, 2005) Other reviews have reported moderate short-term and long-term evidence of success in managing cervical radiculopathy with interlaminar ESIs. (Stav, 1993) (Castagnera, 1994) Some have also reported moderate evidence of management of cervical nerve root pain using a transforaminal approach. (Bush, 1996) (Cyteval, 2004) A previous retrospective review of interlaminar cervical ESIs found that approximately two-thirds of patients with symptomatic cervical radiculopathy from disc herniation were able to avoid surgery for up to 1 year with treatment. Success rate was improved with earlier injection (< 100 days from diagnosis). (Lin, 2006) There have been case reports of cerebellar infarct and brainstem herniation as well as spinal cord infarction after cervical transforaminal injection. (Beckman, 2006) (Ludwig, 2005) Quadriparesis with a cervical ESI at C6-7 has also been noted (Bose, 2005) and the American Society of Anesthesiologists Closed Claims Project database revealed 9 deaths or cases of brain injury after cervical ESI (1970-1999). (Fitzgibbon, 2004) These reports were in contrast to a retrospective review of 1,036 injections that showed that there were no catastrophic complications with the procedure. (Ma, 2005) The American Academy of Neurology concluded that epidural steroid injections may lead to an improvement in radicular lumbosacral pain between 2 and 6 weeks following the injection, but they do not affect impairment of function or the need for surgery and do not provide long-term pain relief beyond 3 months, and there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain. (Armon, 2007) In other studies, there was evidence for short-term symptomatic improvement of radicular symptoms with epidural or selective root injections with corticosteroids, but these treatments did not appear to decrease the rate of open surgery. (Haldeman, 2008) (Benyamin, 2009) Some have said epidural steroid injections should be reserved for those who may otherwise undergo open surgery for nerve root compromise. (Bigos, 1999) There is limited evidence of effectiveness of epidural injection of methyl prednisolone and lidocaine for chronic MND with radicular findings. (Peloso-Cochrane, 2006) The FDA is warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. (FDA, 2014) Recent evidence: ESIs should not be recommended in the cervical region, the FDA's Anesthetic and Analgesic Drug Products Advisory Committee concluded. Injecting a particulate steroid in the cervical region, especially using the transforaminal approach, increases the risk for sometimes serious and irreversible neurological adverse events, including stroke, paraplegia, spinal cord infarction, and even death. The FDA has never approved an injectable corticosteroid product administered via epidural injection, so this use, although common, is considered off-label. Injections into the cervical region, as opposed to the lumbar area, are relatively risky, and the risk for accidental injury in the arterial system is greater in this location. (FDA, 2015) An AMA review suggested that ESIs are not recommended higher than the C6-7 level; no cervical interlaminar ESI should be undertaken at any segmental level without preprocedural review; & particulate steroids should not be used in therapeutic cervical transforaminal injections. (Benzon, 2015) According to the American Academy of Neurology (AAN), ESIs do not improve function, lessen need for surgery, or provide long-term pain relief, and the routine use of ESIs is not recommended. They further said that there is in particular a paucity of evidence for the use of ESIs to treat radicular cervical pain. (AAN, 2015) In this comparative effectiveness study, no significant differences were found between ESI and conservative treatments. (Cohen, 2014) See the Low Back Chapter, where ESIs are recommended as a possible option for short-term treatment of radicular pain in conjunction with active rehab efforts, but they are not recommended for spinal stenosis or for nonspecific low back pain.

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While not recommended, cervical ESIs may be supported using Appendix D, Documenting Exceptions to the Guidelines, in which case: Criteria for the use of Epidural steroid injections, therapeutic: Note: The purpose of ESI is to reduce pain and inflammation, thereby facilitating progress in more active treatment programs, and avoiding surgery, but this treatment alone offers no significant long-term functional benefit.

1. Radiculopathy must be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing.

2. Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle relaxants). 3. Injections should be performed using fluoroscopy (live x-ray) for guidance 4. If used for diagnostic purposes, a maximum of two injections should be performed. A second block is not

recommended if there is inadequate response to the first block. Diagnostic blocks should be at an interval of at least one to two weeks between injections.

5. No more than two nerve root levels should be injected using transforaminal blocks. 6. No more than one interlaminar level should be injected at one session. 7. In the therapeutic phase, repeat blocks should only be offered if there is at least 50% pain relief for six to eight

weeks, with a general recommendation of no more than 4 blocks per region per year. 8. Repeat injections should be based on continued objective documented pain and function response. 9. Current research does not support a “series-of-three” injections in either the diagnostic or therapeutic phase. We

recommend no more than 2 ESI injections. 10. It is currently not recommended to perform epidural blocks on the same day of treatment as facet blocks or

stellate ganglion blocks or sympathetic blocks or trigger point injections as this may lead to improper diagnosis or unnecessary treatment.

11. Cervical and lumbar epidural steroid injection should not be performed on the same day; 12. Additional criteria based on evidence of risk:

a. ESIs are not recommended higher than the C6-7 level; b. Cervical interlaminar ESI is not recommended; & c. Particulate steroids should not be used. (Benzon, 2015)

Criteria for the use of Epidural steroid injections, diagnostic: To determine the level of radicular pain, in cases where diagnostic imaging is ambiguous, including the examples below:

1) To help to evaluate a pain generator when physical signs and symptoms differ from that found on imaging studies; 2) To help to determine pain generators when there is evidence of multi-level nerve root compression; 3) To help to determine pain generators when clinical findings are suggestive of radiculopathy (e.g. dermatomal

distribution), and imaging studies have suggestive cause for symptoms but are inconclusive; 4) To help to identify the origin of pain in patients who have had previous spinal surgery.

The patient meets the criteria using Appendix D to support a Cervical ESI. However, the requested procedure is at the left C5-6 level. Appendix D #12 states as above: ESIs are not recommended higher than the C6-7 level. At this time, a Left selective nerve root block at C5-C6 is not recommended per the ODG and therefore, unfortunately, cannot be certified.

A DESCRIPTION AND THE SOURCE OF THE SCREENING CRITERIA OR OTHER CLINICAL BASIS USED TO MAKE THE DECISION:

X ODG- OFFICIAL DISABILITY GUIDELINES & TREATMENT GUIDELINES