Mountain Pain Specialists, PC

This letter requests redetermination of the denied claim referenced above. The denial cited "medical necessity not established" but the documentation in the medical record meets the medical-necessity criteria set forth in LCD L33930 (Facet Joint Interventions for Pain Management) in effect at the date of service.

Documented Medical Necessity

The patient, a 64-year-old female, has documented bilateral L4-L5 facet arthropathy with the following findings:

• Pain duration: 14 months of axial low back pain with bilateral facet-mediated characteristics
• Conservative therapy exhausted: 12 weeks of physical therapy (Jan–Mar 2026, documented in notes), NSAIDs trial × 6 weeks (intolerable GI side effects), home exercise program adherence verified
• Diagnostic findings: MRI dated 2026-02-08 shows bilateral L4-L5 facet hypertrophy with synovial cyst formation
• Functional impairment: Oswestry Disability Index score of 42 (severe disability) documented at intake
• Diagnostic medial branch blocks: Patient had two prior diagnostic MBBs (2026-02-22 and 2026-03-08) showing >80% pain reduction lasting consistent with anesthetic duration, confirming facet-mediated pain

Per LCD L33930, these findings satisfy all criteria for therapeutic facet joint injection coverage. The denial appears to have been issued without consideration of the diagnostic MBB results in the patient record.

Request

We respectfully request redetermination of this claim. The medical record fully supports the medical necessity standard set by LCD L33930 in effect on the date of service. We have attached supporting documentation referenced above.