I am fighting with my insurance company over injections for my neck. I've had three epidural injections so far and they have really helped. My surgeon is recommending one more and I'm game but my insurance company says they only cover three. They say four injections is not "reasonable or customary." How can I fight this?
Universally accepted guidelines on the use and number of epidural steroid injections (ESI) have not been established or published as yet. That's because research just hasn't shown convincing, reproducible, reliable evidence that this treatment works any better than a placebo. Right now, based on what little evidence there is, the North American Spine Society has issued a statement onthe use of ESI for cervical pain. They have "suggested" a maximum of four injections over a six-month period of time. Since there is no evidence-based accepted guideline in this area, insurance companies are free to set their own limits. The insurance company that administers Medicare coverage in many states currently limits ESI for cervical pain to three injections in a six-month time period. Other private insurance companies use this to determine their limitations as well. Does this mean all patients will get the maximum benefit possible in three treatments? No -- in fact, it is recognized by patients and physicians alike that there may be a variety of individual factors that could make two or four (or some other number of injections) the best choice for some patients. One thing you may be able to take to your insurance company is a letter from your physician stating why a fourth injection is being recommended. It might be helpful if the physician mentioned in that letter of justification what the North American Spine Society's 2011 recommendations are on this point: A maximum of four ESI injections in six months is suggested for cervical radicular pain. An absolute limit of four cervical ESIs per year would seem inappropriate and may overly restrict some patients from receiving necessary and reasonable care. You can find a copy of these recommendations on-line at http://www.spine.org/Documents/CESI_RR_032811.pdf.