CLINICAL APPROPRIATENESS GUIDELINES
Musculoskeletal Program
Appropriate Use Criteria: Interventional Pain Management
for Commercial and Medicare plans (in addition to Blue Cross Community CentennialSM Medicaid in New Mexico)
CHANGES IMPLEMENTED SEPTEMBER 12, 2021 for Medicaid plans except Indiana
CHANGES IMPLEMENTED NOVEMBER 7, 2021 for Indiana Medicaid
ARCHIVED NOVEMBER 7, 2021 for commercial, Medicare and non-Anthem Medicaid
ARCHIVED MARCH 13, 2022 for Anthem Medicaid plans
This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the Carelon Medical Benefits Management website here.
Proprietary
© 2023 Carelon Medical Benefits Management. All rights reserved.
MSK01-0321.2
Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.
Carelon disclaims any responsibility for the completeness or accuracy of the information contained herein.
Table of Contents
CLINICAL APPROPRIATENESS GUIDELINES
Appropriate Use Criteria: Interventional Pain Management
Description and Application of the Guidelines
Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
Paravertebral Facet Injection/Nerve Block/Neurolysis
Regional Sympathetic Nerve Block
Spinal Cord and Nerve Root Stimulators
Description and Application of the Guidelines
The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished:
- To establish criteria for when services are medically necessary
- To assist the practitioner as an educational tool
- To encourage standardization of medical practice patterns
- To curtail the performance of inappropriate and/or duplicate services
- To advocate for patient safety concerns
- To enhance the quality of health care
- To promote the most efficient and cost-effective use of services
The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. Carelon reviews all of its Guidelines at least annually.
Carelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.
Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.
The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines.
The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.
General Clinical Guideline
Clinical Appropriateness Framework
Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:
- Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
- The anticipated benefit of the recommended intervention should outweigh any potential harms that may result (net benefit).
- Current literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
- Based on the clinical evaluation, current literature, and standards of medical practice, there exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.
If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.
Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions
Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.
Additionally, either of the following may apply:
- Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
- One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.
Repeat Diagnostic Intervention
In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.
Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:
- Repeated diagnostic testing at the same facility due to technical issues
- Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
- Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
- Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time
Repeat Therapeutic Intervention
In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered.
Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
Description
Epidural steroid injection (ESI) involves the administration of corticosteroid via insertion of a needle into the epidural space surrounding the spinal nerve root. Despite the lack of consistent evidence to support its efficacy, the procedure is widely used in patients with chronic back, neck and radicular pain. In 2014, the U.S. Food and Drug Administration issued a drug safety communication about epidural injection of glucocorticoids, citing the risk for rare but serious adverse effects (loss of vision, stroke, paralysis, and death). The best evidence supporting its use comes from trials that looked specifically at patients with radiculopathy due to disc herniation, where short term benefit has been demonstrated.
Injections may be performed as part of a diagnostic workup of radicular pain, or as a therapeutic modality when noninvasive treatment strategies have failed. Injections may be performed via an interlaminar approach, transforaminal approach, or caudal approach (through the sacral hiatus at the sacral canal).
Selective nerve root block is a related procedure that utilizes a small amount of anesthetic, injected via transforaminal approach, to anesthetize a specific spinal nerve. Diagnostic selective nerve root blocks are used to evaluate a patient’s anatomical level and/or source of radicular pain and are often used in surgical planning and decision making.
Clinical Indications
The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.
General Requirements
Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including requirements for physical therapy AND at least one complementary conservative management strategy.
Physical therapy requirement includes ANY of the following:
- Physical therapy
- Physician or physical therapist-supervised home treatment program which may include flexibility and muscle strengthening exercises
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative management requirement includes ANY of the following:
- Complementary alternative medicine including, but not limited to, chiropractic care, acupuncture, cognitive behavioral or massage therapy
- Anti-inflammatory medications and analgesics
Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.
Reporting of symptom severity: Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.
Imaging studies: All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiology report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.
Procedural Best Practices to Prevent Neurologic Complications
All providers are expected to adhere to the procedural best practices for epidural steroid injections established by the U.S. Food and Drug Administration (FDA) Safe Use Initiative in 2015. The FDA Safe Use Initiative convened an expert multidisciplinary working group and 13 specialty stakeholder societies to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections. Seventeen procedural clinical considerations aimed at enhancing the safety of these injections, including the appropriate use of particulate steroids, were published. Providers are strongly encouraged to review the consensus opinions of the multidisciplinary working group (see Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations, available at: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2119175).
Note: Preauthorization is required for notification purposes only (medical necessity review is not required) when CPT 62320 and 62322 are used for post-procedural pain with any of the following ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.
Procedural Requirements and Restrictions
- Injections must be performed under fluoroscopy or CT guidance.
- A maximum of four (4) therapeutic injection sessions may be performed in each spinal region (cervical or lumbosacral) in a 12-month period.
- If the initial injection achieves a suboptimal pain response in newly diagnosed patients, a one-time second injection may be performed no sooner than 2 weeks following the initial injection. This second injection is exclusive of the 12-month limit.
- No more than two (2) transforaminal injections may be performed at a single setting (e.g., single level bilaterally or two levels unilaterally). Injecting one level bilaterally would be considered two injections. Injecting two levels, each unilaterally, would also be considered two injections.
- For caudal or cervical/lumbar interlaminar injections, only one injection per session may be performed and NOT in conjunction with a transforaminal injection. A session is defined as all epidural steroid injections or spinal procedures performed on a single day.
- After three (3) injections in the same region, the total cumulative dose of steroid must be documented and may not exceed 240 mg of methylprednisolone or triamcinolone, 36 mg of betamethasone, or 45 mg of dexamethasone.
Therapeutic Epidural Steroid Injection
Therapeutic Epidural Steroid Injection
Therapeutic epidural steroid injection of the cervical or lumbar spine may be indicated when ALL of the following criteria are met:
- Radicular pain (cervical or lumbar) or neurogenic claudication (lumbar) with associated functional impairment
- Evidence of nerve root compression or spinal stenosis (central or foraminal) is seen on an initial advanced imaging study (MRI or CT) performed within the previous 12 months and correlates with the clinical findings*
- The pain has not responded to at least 4 weeks of appropriate conservative management, unless there is evidence of radiculopathy, in which case epidural steroid injection may be performed following 2 weeks of conservative management
*Note: The initial epidural injection for a given episode of pain in the lumbar spine may be performed without confirmatory advanced imaging if the exam findings are clearly diagnostic of nerve root compression or spinal stenosis.
Repeat Therapeutic Epidural Steroid Injection
An injection is considered a repeat injection if the last injection was performed within the previous 12 months. If 12 months or more have elapsed, it is considered a new (initial) injection.
Repeat therapeutic epidural steroid injection may be indicated when ALL of the following criteria are met:
- The prior injection produced at least a 50% reduction in pain with functional improvement of at least 3 weeks’ duration**
- Evidence of nerve root compression or spinal stenosis (central or foraminal) is seen on an initial advanced imaging study (MRI or CT) performed within the previous 12 months and correlates with the clinical findings
- The patient has a recurrence of pain with significant functional disability
- The patient continues to receive conservative treatment between injections
**Note: If the initial therapeutic injection did not result in pain relief, repeat injection may be indicated, provided that the injection is performed utilizing a different approach or type of steroid.
Diagnostic Selective Nerve Root Block
Diagnostic selective nerve root block, also known as diagnostic transforaminal injection, is defined as the injection of anesthetic only, for the purpose of determining the need for surgical intervention.
Diagnostic selective nerve root block may be indicated in the evaluation and diagnostic work-up of radicular pain following consultation with a spine surgeon in ANY of the following scenarios:
- To confirm nerve root compression or spinal stenosis (central or foraminal) noted on an advanced imaging study (MRI or CT) and that is consistent with, and appears to be contributing to, the patient’s symptoms.
- To determine or confirm the (or most) symptomatic level (i.e., site of compression) in the presence of multi-level involvement for which the primary symptomatic level is unclear.
- When radiculopathy is highly suspected but cannot be confirmed with advanced imaging studies.
Contraindications
The following conditions should prompt further evaluation prior to considering epidural steroid injection:
- New onset of low back pain or neck pain in the setting of established malignancy, or where there is a suspicion of malignancy based on the clinical presentation
- New onset of low back pain or neck pain in persons with risk factors for spinal infection
- Comorbid conditions associated with increased risk of bleeding due to coagulopathy or treatment with anticoagulants
- Back pain in the setting of trauma
Additional contraindications include the following conditions:
- Cauda equina syndrome
- Conus medullaris syndrome
- Epidural hematoma
- Subarachnoid hemorrhage
- Epidural mass
- Spinal cord ischemia
- Spinal fracture which occurred less than 6 weeks prior to injection
- Demyelinating disease or other CNS processes which predispose to transverse myelitis
- Systemic infection
- Local infection at the injection site
- Uncontrolled diabetes
Exclusions
Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to the following:
- Thoracic level epidural steroid injection performed for thoracic pathology
- Moderate-to-severe myelopathy on clinical exam
- Myelopathy associated with intramedullary cord signal change on T1 or T2 weighted MRI
- Isolated axial neck pain or low back pain
- Intradiscal spinal injections (including but not limited to chymopapain, collagenase, chondroitin sulfate ABC endolyase, condoliase, and oxygen-ozone) for chemonucleolysis
- Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid or epidural
Selected References
- Ammendolia CS, K. J.; Rok, E.; Rampersaud, R.; Kennedy, C. A.; Pennick, V.; Steenstra, I. A.; de Bruin, L. K.; Furlan, A. D. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013(8):CD010712.
- Bicket MC, Horowitz JM, Benzon HT, et al. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. The spine journal : official journal of the North American Spine Society. 2015;15(2):348-62.
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34(10):1066-77.
- Cohen SPH, S.; Semenov, Y et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045-55.
- COST B13 Working Group on Guidelines for Chronic Low Back Pain, Airaksinen O, Brox JI, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.
- COST B13 Working Group on Guidelines for Chronic Low Back Pain, van Tulder M, Becker A, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-91.
- Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain physician. 2012;15(6):E839-68.
- Institute for Clinical Systems Improvement GM, Thorson D, et al. . Adult acute and subacute low back pain. 2012:92 pgs.
- Institute of Health Economics. Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. 2011:37.
- Kaye ADM, L.; Abdi, S.; et al. Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis. Pain physician. 2015;18(6):E939-1004.
- Kreiner DS, Hwang, S. W., North American Spine, Society, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-91.
- Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The spine journal : official journal of the North American Spine Society. 2013;13(7):734-43.
- Lee CHL, J.; Kang, J. D. et al. . Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: a meta-analysis of clinical and radiological outcomes. J Neurosurg Spine. 2015;22(6):589-95.
- Lewis RAW, N. H.; Sutton, A. J., et al. . Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015;15(6):1461-77.
- Liu KL, P.; Liu, R.; Wu, X.; Cai, M. Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Des Devel Ther. 2015;9:707-16.
- MacVicar JK, W.; Landers, M. H.; Bogduk, N. The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data. Pain Medicine. 2013;14(1):14-28.
- Manchikanti LB, R. M.; Falco, F. J.; Kaye, A. D.; Hirsch, J. A. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop. 2015;473(6):1940-56.
- Manchikanti LN, D. E.; Candido, K. D., et al. . Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review. Pain physician. 2015;18(1):39-60.
- Meng HF, Q.; Wang, B.; Yang, Y.; Li, D.; Li, J.; Su, N. Epidural injections with or without steroids in managing chronic low back pain secondary to lumbar spinal stenosis: a meta-analysis of 13 randomized controlled trials. Drug Des Devel Ther. 2015;9:4657-67.
- National Institute for Health and Care Excellence,Low back pain and sciatica in over 16s: assessment and management,(2016),London UK,
- North American Spine Society,Lumbar Epidural Injections – NASS Coverage Policy Recommendations,(May 2014),Burr Ridge IL,12 pgs.
- North American Spine Society,Cervical Epidural Infections – NASS Coverage Policy Recommendations,(May 2014),Burr Ridge IL 10 pgs.
- Phillips FMS, P. J.; Youssef, J. A.; Andersson, G.; Papatheofanis, F. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: a systematic review. Spine. 2013;38(7):E409-22.
- Pinto RZM, C. G.; Ferreira, M. L., et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):865-77.
- Radcliff KK, C.; Hilibrand, A., et al. . Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial. Spine. 2013;38(4):279-91.
- Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations. Anesthesiology. 2015;122(5):974-84.
- Zhang YL, C.; Tao, Y., et al. Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials. PLoS ONE. 2015;10(3):e0117826.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
*Note: Preauthorization is required for notification purposes only (medical necessity review is not required) when CPT 62320 and 62322 are used for postprocedural pain with any of the following ICD-10-CM diagnoses: G89.11 Acute pain due to trauma, G89.12 Acute post-thoracotomy pain, or G89.18 Other acute post procedural pain.
CPT/HCPCS
62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid
62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic
62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)
62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar
62320* Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
62322* Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
64479 Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
64480 Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
64483 Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
64484 Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
Paravertebral Facet Injection/Nerve Block/Neurolysis
Description
Paravertebral facet joints, also referred to as zygapophyseal joints or Z-joints, have been implicated as a source of chronic neck and low back pain with a prevalence of up to 70% in the cervical spine, and up to 30% in the lumbar spine. Neither physical exam nor imaging has adequate diagnostic power to confidently identify the facet joint as a pain source. Facet joint injection techniques have evolved primarily as a diagnostic tool for pain originating in these joints, but have been widely utilized to treat chronic pain shown to be of facet origin.
Injections may be performed at one of two sites, either the joint itself (intraarticular injection) or the nerve that supplies it (medial branch of the dorsal ramus of segmental spinal nerves). Diagnostic injections are performed with an anesthetic agent alone, while therapeutic injections involve administration of a corticosteroid, with or without an anesthetic. Following confirmation of facet pathology using a diagnostic medial branch block, select patients may undergo a radiofrequency nerve ablation procedure. Studies have validated the efficacy of this intervention in chronic pain of facet origin.
Clinical Indications
The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.
General Requirements
Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including requirements for physical therapy AND at least one complementary conservative management strategy.
Physical therapy requirement includes ANY of the following:
- Physical therapy
- Physician or physical therapist-supervised home treatment program which may include flexibility and muscle strengthening exercises
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative management requirement includes ANY of the following:
- Complementary alternative medicine including, but not limited to, chiropractic care, acupuncture, cognitive behavioral or massage therapy
- Anti-inflammatory medications and analgesics
Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.
Reporting of symptom severity: Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.
Imaging studies: All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiology report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.
Patient Requirements
Patients must meet ALL of the following criteria:
- Moderate-to-severe pain with functional impairment of at least 3 months’ duration
- Predominant axial pain that is not attributable to radiculopathy (with the exception of synovial cysts), myelopathy, or neurogenic claudication
- Physical exam findings which are consistent with the facet joint as the presumed source of pain
- Absence of non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, or infection
- Absence of prior surgical fusion at the proposed level
- Lack of improvement or resolution following at least 6 weeks of conservative management
Procedural Requirements
Procedures must be performed with image guidance, either fluoroscopy or CT.
Diagnostic Medial Branch Blocks with Local Anesthetic
The primary utility of medial branch blocks (MBB) is to determine the suitability of the patient for a radiofrequency neurotomy of painful segmental levels in order to achieve long-term pain management. A positive response is defined as at least 80% relief of the primary (index) pain, with the onset and duration of relief being consistent with the agent employed.
Note: The patient must be experiencing pain at the time of the injection (generally rated at least 3 out of 10 in intensity) in order to determine whether a response has occurred. Provocative maneuvers or positions which normally exacerbate index pain should also be assessed and documented before and after the procedure. Diagnostic medial branch blocks are to be performed with local anesthetic agents only. The concurrent use of steroids are not medically necessary as they may compromise the integrity of the diagnostic test.
- Dual medial branch blocks, defined as injections performed in the same location(s) on two separate occasions at least one week apart, are necessary to confirm the diagnosis due to the unacceptably high false positive rate of single medial branch block injections.
- A confirmatory injection is indicated only if the first injection results in a positive response. If the second injection also results in a positive response, the target joint(s) is/are the confirmed pain generator(s).
- If the first session of diagnostic medial branch blocks are negative, a maximum of one (1) additional session may be performed to determine the primary levels of involvement prior to proceeding with confirmatory blocks.
- For each covered spinal region (cervical or lumbar), diagnostic medial branch blocks should be performed at no more than two (2) bilateral levels or three (3) unilateral levels per session.
Therapeutic Intraarticular Facet Joint Injections
Patients must meet BOTH of the following criteria to receive therapeutic intraarticular (IA) facet joint injection:
- Evidence of nerve root compression due to a facet synovial cyst when seen on an advanced imaging study (MRI or CT) performed within the previous 12 months that correlates with the clinical findings
- Associated moderate-to-severe radicular pain and functional limitations
Thermal Medial Branch Radiofrequency Neurotomy
- Medial branch radiofrequency neurotomy (RFN) may be offered to patients if dual diagnostic medial branch block injections each produce at least 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed.
- Radiofrequency neurotomy may be performed at the same level no more than twice annually and only if the initial radiofrequency lesion results in significant pain relief (at least 50%) and improvement in patient specific ADLs for at least 6 months.
- For each covered spinal region (cervical or lumbar), radiofrequency neurotomy should be performed at no more than two (2) bilateral levels or three (3) unilateral levels.
- Repeat radiofrequency neurotomy to treat recurrent facet joint pain in a patient who has failed other conservative measures may be indicated without repeating diagnostic medial branch block injections if the patient has experienced significant and prolonged relief of pain (at least 50% reduction for at least 6 months) and improvement of function in the past following radiofrequency ablation.
- Radiofrequency neurotomy may not be performed at C0-C1 or at C1-C2.
Procedural Limitations
The following limitations apply to diagnostic medial branch blocks and therapeutic intraarticular facet joint injections:
- One (1) additional diagnostic block may be indicated prior to a repeat neurotomy when there is diagnostic uncertainty about the source of pain
- A maximum of six (6) facet joint procedural sessions per region (cervical or lumbar) may be performed in a 12-month period, regardless of type or indication.
Exclusions
Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to the following:
- Diagnostic intraarticular facet joint injection
- Therapeutic medial branch block
- Therapeutic intraarticular facet joint injection for any other indication not listed above
- Use of corticosteroid with diagnostic medial branch block
- Diagnostic or therapeutic intraarticular injection, medial branch block, or radiofrequency ablation in the thoracic region with the exception of C7-T1 and T12-L1
- Use of medial branch block or radiofrequency neurotomy in the setting of moderate-to-severe spondylolisthesis (grade 2 or higher)
- Use of medial branch block or radiofrequency neurotomy in the setting of an isolated pars defect
- Use of medial branch block or radiofrequency neurotomy at the level of a prior fusion
- Use of chemical neurolysis for medial branch ablation
- Use of laser neurolysis for medial branch ablation
- Use of cryodenervation (cryoablation) for medial branch ablation
- Use of cooled radiofrequency denervation for medial branch ablation
- Use of pulsed radiofrequency denervation for medial branch ablation
- Any facet joint interventions performed under ultrasound guidance
- Intraarticular or extraarticular facet joint prolotherapy
- Radiofrequency neurolysis for sacroiliac joint pain
Selected References
- Boswell MV, Manchikanti L, Kaye AD, et al. A Best-Evidence Systematic Appraisal of the Diagnostic Accuracy and Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain. Pain physician. 2015;18(4):E497-533.
- Centers for Medicare and Medicaid Services, Local Coverage Determinations: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy, (2016) Baltimore MD, 62 pgs.
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34(10):1066-77.
- COST B13 Working Group on Guidelines for Chronic Low Back Pain, Airaksinen O, Brox JI, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.
- Falco FJ, Manchikanti L, Datta S, et al. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain physician. 2012;15(6):E839-68.
- Lee CHL, J.; Kang, J. D. et al. . Laminoplasty versus laminectomy and fusion for multilevel cervical myelopathy: a meta-analysis of clinical and radiological outcomes. J Neurosurg Spine. 2015;22(6):589-95.
- Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician. 2013;16(2 Suppl):S49-283.
- Manchikanti LB, R. M.; Falco, F. J.; Kaye, A. D.; Hirsch, J. A. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop. 2015;473(6):1940-56.
- North American Spine Society, Facet Joint Interventions – NASS Coverage Policy Recommendations, (August 2016) Burr Ridge IL, 16 pgs.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
CPT/HCPCS
0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)
0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)
0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
64625 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
64640 Destruction by neurolytic agent; other peripheral nerve or branch
Regional Sympathetic Nerve Block
Description
Sympathetic blockade includes procedures that temporarily obstruct the local function of the sympathetic nervous system. Anesthetic is injected directly into sympathetic neural structures that serve affected limb(s), such as the stellate ganglion or the lumbar sympathetic chain. Radiologic guidance (fluoroscopy or CT scan) is utilized to ensure accuracy.
Regional sympathetic nerve block has been utilized primarily for treatment of complex regional pain syndrome. Despite limited evidence supporting its efficacy, it has also been investigated in treating a number of other pain syndromes thought to be sympathetically mediated.
This and other interventional procedures should be considered only when the full spectrum of noninvasive management strategies has not provided sufficient relief of symptoms.
Clinical Indications
The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.
General Requirements
Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including requirements for physical therapy AND at least one complementary conservative management strategy.
Physical therapy requirement includes ANY of the following:
- Physical therapy
- Physician or physical therapist-supervised home treatment program which may include flexibility and muscle strengthening exercises
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative management requirement includes ANY of the following:
- Complementary alternative medicine including, but not limited to, chiropractic care, acupuncture, cognitive behavioral or massage therapy
- Anti-inflammatory medications and analgesics
Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.
Reporting of symptom severity: Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.
Imaging studies: All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiology report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.
Complex Regional Pain Syndrome (Type I or Type II)
Diagnostic criteria for complex regional pain syndrome (CRPS) must be met:
- Continuing pain that is disproportionate to any inciting event
- At least ONE symptom reported in at least THREE (3) of the following categories:
- Sensory: Hyperesthesia or allodynia
- Vasomotor: Temperature asymmetry, skin color changes, skin color asymmetry
- Sudomotor/edema: Edema, sweating changes, or sweating asymmetry
- Motor/trophic: Decreased range of motion, motor dysfunction (e.g., weakness, tremor, dystonia), or trophic changes (e.g., hair, nail, skin)
- At least ONE sign at time of evaluation in at least TWO (2) of the following categories:
- Sensory: Evidence of hyperalgesia (to pinprick), allodynia (to light touch, temperature sensation, deep somatic pressure, or joint movement)
- Vasomotor: Evidence of temperature asymmetry (>1°C), skin color changes or asymmetry
- Sudomotor/edema: Evidence of edema, sweating changes, or sweating asymmetry
- Motor/trophic: Evidence of decreased range of motion, motor dysfunction (e.g., weakness, tremor, dystonia), or trophic changes (e.g., hair, nail, skin)
- No other diagnosis better explaining the signs and symptoms
- In addition, ALL of the following are required:
- Level of pain and disability in the moderate-to-severe range
- Failure of at least 2 weeks of conservative management
- Documentation of ongoing participation in a comprehensive pain management program
The performance of an initial diagnostic regional sympathetic block is considered medically necessary to establish the presence or absence of sympathetically mediated complex regional pain syndrome. A positive response is defined as a significant reduction in pain (at least 80% reduction) and improvement in function with the duration of relief being consistent with agent employed, and objective evidence that the block was physiologically effective.
For procedures that target pain in a limb, there must be documentation of a rise in temperature from baseline of the ipsilateral limb. A sensory exam is required to confirm absence of spread to adjacent nerve roots.
Following a positive response to the initial diagnostic block,additional diagnostic and therapeutic regional sympathetic blocks, up to maximum of six (6) total blocks, performed at a frequency of no more than two (2) per week, may be considered medically necessary when ALL the following criteria have been met:
- Benefit has been demonstrated by prior blocks as evidenced by ALL of the following:
- Decreased use of pain medication
- Improved level of function (e.g., increased range of motion, strength, and use of extremity in activities of daily living)
- Improved tolerance to touch (e.g., decreased allodynia) or other objective measures
- The intervention is being provided as part of a comprehensive pain management program (physical therapy, patient education, psychosocial support, and oral medication).
- If there is no sustained benefit in pain and function after three (3) sympathetic blocks from baseline (pre block) pain and function, then additional blocks are not warranted.
- If there is sustained benefit after the first three (3) sympathetic blocks then up to three (3) additional blocks may be performed.
Exclusions
Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to the following:
- Use of intravenous phentolamine (Regitine) as a diagnostic test for CRPS
- Intravenous regional sympathetic block utilizing guanethidine
- Intrapleural analgesia for treatment of CRPS
Selected References
- Harden RN, Oaklander AL, Burton AW, Perez RS, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S; Reflex Sympathetic Dystrophy Syndrome Association. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med. 2013 Feb;14(2):180-229. doi: 10.1111/pme.12033. Epub 2013 Jan 17.
- O’Connell NEW, B. M.; Gibson, W., et al. . Local anaesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev. 2016;7:CD004598.
- Zernikow BW, J.; Brehmer, H.; Hirschfeld, G.; Maier, C. Invasive treatments for complex regional pain syndrome in children and adolescents: a scoping review. Anesthesiology. 2015;122(3):699-707.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
CPT/HCPCS
64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
Sacroiliac Joint Injection
Description
Noninflammatory sacroiliac (SI) joint complex pain may be traumatic, degenerative, or due to adjacent segment disease (after lumbar fusion or total hip replacement). Sacroiliitis is associated with inflammatory spondyloarthropathies. Pain arising from the sacroiliac joint complex typically radiates to the gluteal area and posterior hip. In addition to localized tenderness over the sacroiliac joint, there are additional examination maneuvers which suggest the diagnosis.
Clinical Indications
The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.
General Requirements
Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including requirements for physical therapy AND at least one complementary conservative management strategy.
Physical therapy requirement includes ANY of the following:
- Physical therapy
- Physician or physical therapist-supervised home treatment program which may include flexibility and muscle strengthening exercises
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative management requirement includes ANY of the following:
- Complementary alternative medicine including, but not limited to, chiropractic care, acupuncture, cognitive behavioral or massage therapy
- Anti-inflammatory medications and analgesics
Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.
Reporting of symptom severity: Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.
Imaging studies: All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiology report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.
Patient Requirements
Patients must meet ALL of the following criteria to be able to proceed with diagnostic intraarticular sacroiliac joint injections, therapeutic intraarticular sacroiliac joint injections, or diagnostic lateral branch blocks.
- There is persistent typically unilateral non-radicular pain that is predominantly below the lumbar spine (L5) and is primarily localized over the region of the sacroiliac joint and has been present for at least 3 months
- Examination shows localized tenderness with palpation over the sacral sulcus just inferior to the posterior superior iliac spine (PSIS) in the absence of tenderness of equal severity elsewhere (e.g., lumbar spine, greater trochanter, hip, coccyx)
- At least ONE of the following provocative tests is positive: pelvic distraction test, lateral iliac compression test, sacral compression/thrust test, thigh thrust test, FABER (Patrick’s test), and Gaenslen’s test
- There is no evidence of acute or subacute radicular pain/radiculopathy or neurogenic claudication. If there is evidence of radicular pain/radiculopathy or neurogenic claudication, the condition must be fixed and stable and have been maximally addressed through comprehensive treatment
- Lack of adequate improvement following 6 weeks of conservative management
Procedural Requirements
Procedures must be performed with image guidance, either fluoroscopy or CT.
Sacroiliac Joint Injections
Diagnostic intraarticular sacroiliac joint injections
The primary utility of diagnostic intraarticular sacroiliac joint injections is to determine if the sacroiliac joint is the primary pain generator for the patient’s low back pain.
- Dual intraarticular sacroiliac joint injections, defined as injections performed in the same joint on two separate occasions, are necessary to confirm the diagnosis due to the unacceptably high false positive rate of single intraarticular sacroiliac joint injections.
- A second confirmatory injection is indicated only if the first injection produces at least 75% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed. This confirmatory block confirms the tested sacroiliac joint as the source if the index pain is reduced by at least 75% and the onset and minimum duration of relief is consistent with the agent employed.
- Anesthetic volume must be limited to 1.5 cc to maximize the anatomic specificity of the procedure. Concurrent injection of steroid is not appropriate for diagnostic sacroiliac joint injection.
- On the day of the procedure, the patient’s pain must be at least 3 out of 10 in severity at rest or during a consistently provocative maneuver, which will allow accurate monitoring of the response to the injection.
Therapeutic intraarticular sacroiliac joint injections
- Therapeutic intraarticular sacroiliac joint injections are performed with the use of corticosteroid with or without the use of anesthetic.
- Total injection volume should be limited to 2.0 cc to minimize extravasation of the injectate outside of the sacroiliac joint.
Repeat therapeutic intraarticular sacroiliac joint injections
- Repeat injection is considered medically necessary if symptoms recur and the patient has demonstrated at least 50% pain relief, and improvement in patient-specific ADLs, for at least 6 weeks after a previous injection.
- Injections may not be repeated at intervals of less than 3 months, with a maximum of three (3) injections in a 12-month period.
- Treatment with therapeutic injections should be accompanied by participation in an ongoing active rehabilitation program, home exercise program, or functional restoration program.
Ultrasound guidance
- Ultrasound is the only imaging guidance appropriate for use during pregnancy.
Exclusions
Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to the following:
- Intraarticular sacroiliac joint injections performed on the same day as other spine injection procedures
- Use of corticosteroid with diagnostic intraarticular sacroiliac joint injections
- Diagnostic or therapeutic injection (anesthetic and/or steroid) of nerves innervating the sacroiliac joint
Selected References
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34(10):1066-77.
- COST B13 Working Group on Guidelines for Chronic Low Back Pain, Airaksinen O, Brox JI, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.
- Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain physician. 2012;15(3):E247-78.
- Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician. 2013;16(2 Suppl):S49-283.
- Muheremu AN, X.; Wu, Z.; et al. . Comparison of the short- and long-term treatment effect of cervical disk replacement and anterior cervical disk fusion: a meta-analysis. Eur. 2015;25 Suppl 1:S87-100.
- North American Spine Society,Sacroiliac Joint Injections – NASS Coverage Policy Recommendations, (2015) ,Burr Ridge IL, 11 pgs.
- Zaidi HAM, A. J.; Dickman, C. A. Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. J Neurosurg Spine. 2015;23(1):59-66.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
CPT/HCPCS
27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed
64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (i.e. fluoroscopy or computed tomography)
G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
Spinal Cord and Nerve Root Stimulators
Description
Spinal cord stimulators, also known as dorsal column stimulators (“stimulators”), are implantable devices used to treat chronic pain. Electrodes are surgically placed within the dura mater via laminectomy, or by percutaneous insertion into the epidural space. Low voltage electrical signals are delivered to the dorsal column of the spinal cord in order to override or mask sensations of pain.
The patient’s pain distribution pattern determines the level at which the stimulation lead is placed. The lead may incorporate 4 to 8 electrodes, with 8 electrodes typically used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk.
Implantation is typically a two-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio receiver/ transducer are permanently implanted.
Extensive programming of the neurostimulators is often required to achieve optimal pain control.
Clinical Indications
The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.
General Requirements
Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including requirements for physical therapy AND at least one complementary conservative management strategy.
Physical therapy requirement includes ANY of the following:
- Physical therapy
- Physician or physical therapist-supervised home treatment program which may include flexibility and muscle strengthening exercises
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative management requirement includes ANY of the following:
- Complementary alternative medicine including, but not limited to, chiropractic care, acupuncture, cognitive behavioral or massage therapy
- Anti-inflammatory medications and analgesics
Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.
Reporting of symptom severity: Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.
Imaging studies: All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiology report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.
Spinal Cord Stimulation
Spinal cord stimulation (including burst, high frequency, and traditional stimulation methods)
Stimulator Trial
Stimulator trial may be indicated when ALL of the following criteria are met:
- The patient has chronic intractable neuropathic pain of the trunk and/or limbs associated with at least ONE of the following conditions:
- Lumbosacral arachnoiditis as documented by high levels of protein in the cerebrospinal fluid and/or imaging (MRI or myelography)
- Nerve root injuries that are post-surgical or post-traumatic, including post-laminectomy syndrome (failed back syndrome)
- Complex regional pain syndrome (CRPS), type I or type II (formerly known as reflex sympathetic dystrophy or causalgia)
- Severe pain and disability with documented pathology or an objective basis for the pain
- Dorsal column stimulation is being used as a late or last resort after documented failure of at least 6 consecutive months of physician-supervised conservative management
- There is no evidence of existing untreated drug addiction
- The patient has been evaluated by a pain management specialist prior to implantation
- All the facilities, equipment, and professional and support personnel required for the proper diagnosis, treatment training, and follow-up of the patient must be available
- At least one surgical opinion has been obtained to ensure that the patient does not have a surgically correctable lesion
- Documentation of an evaluation by a mental health provider (e.g., a face-to-face assessment with or without psychological questionnaires and/or psychological testing) that confirms no evidence of an inadequately controlled mental health problem (e.g., alcohol or drug dependence, depression, psychosis) that would negatively impact the success of a spinal cord stimulator or contraindicate its placement
Stimulator Implantation (Permanent)
Stimulator implantation (permanent) may be indicated when ALL of the following criteria are met:
- The patient meets all of the criteria for a stimulator trial
- A stimulator trial of at least 3 days duration has been performed
- Documented pain reduction and functional improvement following the stimulator trial with at least a 50% reduction of target pain or analgesic medication use, and specific evidence of improved function
Stimulator Revision or Removal
Stimulator revision or removal may be indicated when ANY of the following criteria are met:
- Stimulator hardware complication including
- Lead migration
- Infection
- Painful generator site
- Stimulator response complications including
- Loss of effectiveness
- Patient intolerance
- Development of new neurologic deficits
- Planned procedure where stimulators are contraindicated including
- Magnetic resonance imaging
- Automatic implantable cardioverter defibrillator
Dorsal Root Ganglion Stimulation
Dorsal root ganglion stimulation may be indicated as an alternative to dorsal column stimulation in patients with moderate-to-severe chronic intractable pain of the lower limbs from complex regional pain syndrome (CRPS) types I or II and who otherwise meet above criteria for spinal cord stimulator trial or implantation.
Exclusions
Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to the following:
- Use of spinal cord stimulation for the treatment of critical limb ischemia to forestall amputation, refractory angina pectoris, heart failure, and cancer-related pain
- Dorsal root ganglion neurostimulation for any non-CRPS lower extremity indication
- Dorsal root ganglion neurostimulation in patients with CRPS lower extremity who currently have a spinal cord stimulator or who have previously failed spinal cord stimulation therapy
- Simultaneous placement of a dorsal column and dorsal root ganglion stimulator
- Replacement of a conventional spinal cord stimulator with a burst, high frequency, or dorsal root ganglion stimulator in the absence of an indication for stimulator removal
Selected References
- Centers for Medicare and Medicaid Services, National Coverage Determination for Electrical Nerve Stimulators, (1995) Baltimore MD, 3 pgs.
- Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34(10):1066-77.
- COST B13 Working Group on Guidelines for Chronic Low Back Pain, Airaksinen O, Brox JI, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.
- Lewis RAW, N. H.; Sutton, A. J., et al. . Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015;15(6):1461-77.
- Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician. 2013;16(2 Suppl):S49-283.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
CPT/HCPCS
63650 Percutaneous implantation of neurostimulator electrode array, epidural
63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed
63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed
63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver
C1767 Generator, neurostimulator (implantable), nonrechargeable
C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system
C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system
L8679 Implantable neurostimulator, pulse generator, any type
L8680 Implantable neurostimulator electrode, each
L8682 Implantable neurostimulator radiofrequency receiver
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
L8688 Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension