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 (i.e., in general, shown to be effective in improving health outcomes and considered the most appropriate level of service)
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. Pharmaceuticals, radiotracers, or medical devices used in any of the diagnostic or therapeutic interventions listed in the Guidelines must be FDA approved or conditionally approved for the intended use. However, use of an FDA approved or conditionally approved product does not constitute medical necessity or guarantee reimbursement by the respective health plan.

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).

Diagnostic selective nerve root block (SNRB) is a related procedure that utilizes a small amount of anesthetic, injected via transforaminal approach, to anesthetize a specific spinal nerve root. Diagnostic SNRBs 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 Information

The terms in the section provide operational definitions when they are referenced as requirements in the guideline.

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 managementrequirement includes ANY of the following:
- Anti-inflammatory medications and analgesics
- Complementary alternative medicine including, but not limited to, acupuncture, chiropractic care, cognitive behavioral or massage therapy

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.

Epidural Injections

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, thoracic, or lumbosacral) in a 12-month period regardless of the type of approach (transforaminal, interlaminar, or caudal. If the initial injection does not result in pain relief or 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/thoracic/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.
Epidural injections should not be combined with any other procedure on spine except under special circumstances such as presence of a large facet joint synovial cyst or large effusion compressing a spinal nerve root in which case a transforaminal injection combined with an intraarticular facet synovial cyst aspiration and steroid injection may be given together.
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 (Interlaminar, Caudal, Transforaminal)

Therapeutic epidural steroid injection of the cervical, thoracic, or lumbar spine may be indicated when ALL of the following criteria are met:

Significant radicular pain, radiculopathy (cervical, thoracic, or lumbar), or neurogenic claudication (lumbar) with associated functional impairment
Evidence of EITHER of the following is seen on an advanced imaging study* (MRI or CT) and correlates with the clinical findings:
- Nerve root compression secondary to herniated disc (advanced imaging should be performed within the previous 18 months)
- Spinal stenosis (central, lateral recess, foraminal, extraforaminal)
The pain has not responded to at least 4 weeks of appropriate conservative management, unless there is clear evidence of radiculopathy**, in which case epidural steroid injection may be performed following 2 weeks of conservative management

* 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.

**Clear evidence of radiculopathy is defined as pain distributed along specific nerve root with corresponding sensory changes, muscle weakness, and, where applicable, positive nerve root irritation sign.

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:

Significant radicular pain, radiculopathy (cervical, thoracic, or lumbar), or neurogenic claudication (lumbar) with associated functional impairment
The prior injection produced at least a 50% reduction in pain with functional improvement of at least 3 weeks’ duration
Confirmed evidence demonstrated on advanced imaging (MRI or CT) which correlates with the clinical findings. For herniated nucleus pulposus (HNP), advanced imaging should be performed within the previous 18 months of current request. This imaging requirement is waived for repeat injection if previously satisfied for the initial injection of EITHER of the following:
- Nerve root compression secondary to herniated disc
- Spinal stenosis (central, lateral recess, foraminal, or extraforaminal)
The patient continues to receive conservative management between injections

Diagnostic Selective Nerve Root Block

Diagnostic selective nerve root block (SNRB) 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 when ALL of the following criteria are met:

Presence of significant radicular pain or radiculopathy (cervical, thoracic, or lumbar) with associated functional impairment.
The pain has not responded to at least 4 weeks of appropriate conservative management
Surgery is being considered and documented by appropriate surgical consult in ANY of the following scenarios:
- To confirm nerve root compression 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 known or suspected conditions:

Cauda equina syndrome
Conus medullaris syndrome
Epidural hematoma
Epidural abscess
Epidural mass
Subarachnoid hemorrhage
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:

Moderate-to-severe myelopathy on clinical exam
Myelopathy associated with intramedullary cord signal change on T1 or T2 weighted MRI
Isolated axial neck pain, mid-back 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
Diagnostic selective nerve root block at more than one level in one session
More than two sessions for selective nerve root block

Combined multiple spinal injections regardless of spinal region (e.g., epidural and facet injections) in a single session (except under special circumstances such as presence of a large facet joint synovial cyst compressing a spinal nerve root, in which case a transforaminal injection combined with an intraarticular facet synovial cyst aspiration and steroid injection may be given together)

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. 2018:49 pgs.
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.
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.
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,
Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4:CD013577.
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.
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.
Smith CC, McCormick ZL, Mattie R, et al. The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data. Pain Med. 2019;25:25

Codes

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

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.

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)
62326	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); without imaging guidance
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/Medial Branch 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 Information

The terms in the section provide operational definitions when they are referenced as requirements in the guideline.

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

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 managementrequirement includes ANY of the following:
- Anti-inflammatory medications and analgesics
- Complementary alternative medicine including, but not limited to, acupuncture, chiropractic care, cognitive behavioral or massage therapy

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

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 after completing at least 6 weeks of conservative management for the current condition or episode of pain

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 is not medically necessary, as it 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 (defined as at least 80% or more relief in primary pain index). 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 is negative, a maximum of one (1) additional session may be performed to determine the primary levels of involvement prior to proceeding with confirmatory blocks.
A maximum of only 2 diagnostic sessions per level given on separate occasions are appropriate and medically necessary for determination of the patient’s candidacy for radiofrequency ablation in a given year (cervical or lumbar).
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.
A single or dual diagnostic medial branch block may be indicated for confirming a pars defect as the primary pain generator for low back pain (except in isolated pars defects in young athletes). Documentation of planned surgery or surgical consultation is required.

Therapeutic Intraarticular Facet Joint Injections

Therapeutic intraarticular facet injections may be medically necessary only under the following conditions:

There is suspected inflammatory facetogenic pain due to systemic arthropathies (e.g., rheumatoid arthritis)
Denervation is contraindicated (e.g., young athletic person in whom denervation may result in muscle atrophy that can adversely impact their condition [e.g., spondylolisthesis] or ADLs)
Individuals at risk for complications with radiofrequency neurotomy treatment (e.g., pacemaker-dependent patients and those with automatic implantable cardioverter-defibrillators, presence of another electronic device such as a spinal cord stimulator or an intrathecal infusion device, older individuals on anticoagulation therapy)
For any of the above conditions only, therapeutic facet joint injection may be repeated at the same anatomic site for recurrent pain if the prior injection provided at least 50% reduction in pain with functional improvement of at least 3 months’ duration
Evidence of nerve root compression due to a facet synovial cyst or large effusion. Patients must meet ALL of the following criteria to receive therapeutic intraarticular facet joint injection:
- Evidence of nerve root compression due to a facet synovial cyst/large effusion 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
- Cyst aspiration/rupture may be repeated once within the 12-month period and only if there is consistent pain reduction of 50% or more for a minimum of three (3) months

The use of therapeutic intraarticular facet injections is considered not medically necessary for all other indications.

Thermal Medial Branch Radiofrequency Neurotomy

Medial branch radiofrequency neurotomy (RFN) may be offered to patients if dual diagnostic medial branch block injections (with local anesthetic only without any steroids), performed within the last 6 months, each produce at least 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the local anesthetic 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. One confirmatory diagnostic medial branch block may be indicated but not necessary to confirm the same involved facet level.
Radiofrequency neurotomy may not be performed at C0-C1 or at C1-C2.

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
Diagnostic medial branch blocks for reasons other than candidacy for radiofrequency ablation
Therapeutic medial branch block (use of corticosteroid with diagnostic medial branch block)
Therapeutic intraarticular facet joint injection for any other indication not listed above
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 3 or higher)
Use of medial branch block or radiofrequency neurotomy in the setting of an isolated pars defect (except diagnostic medial branch block for pars defect diagnosis work-up)
Use of medial branch block or radiofrequency neurotomy at the level of a prior spinal fusion
Use of chemical neurolysis for medial branch ablation
Use of laser neurolysis for medial branch ablation
Use of open surgical neurolysis
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
Facet joint procedures in more than one spinal region in a single session
Combined multiple spinal injections regardless of spinal region (e.g., epidural and facet injections) in a single session (except under special circumstances such as presence of a large facet joint synovial cyst compressing a spinal nerve root in which case a transforaminal injection combined with an intraarticular facet synovial cyst aspiration and steroid injection may be given together).

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.
Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020;45(6):424–467.
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.
Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain Med. 2021;22(11):2443-524.
Lee DW, Pritzlaff S, Jung MJ, et al. Latest Evidence-Based Application for Radiofrequency Neurotomy (LEARN): Best Practice Guidelines from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2021;14:2807-31.
Manchikanti L, Kaye AD, Soin A, et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain physician. 2020;23(3S):S1-S127.
Manchikanti L, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain physician. 2021;24(S1):S27-S208
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.

Codes

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)
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)

Regional Sympathetic Nerve Block

Description

Sympathetic blockade includes procedures that temporarily obstruct the local function of the sympathetic nervous system. Anesthetic is injected directly over the 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 Information

The terms in the section provide operational definitions when they are referenced as requirements in the guideline.

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

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 managementrequirement includes ANY of the following:
- Anti-inflammatory medications and analgesics
- Complementary alternative medicine including, but not limited to, acupuncture, chiropractic care, cognitive behavioral or massage therapy

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

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
Interpleural analgesia for treatment of CRPS
Use of sympathetic block CPT code for blocks other than stellate ganglion block and lumbar sympathetic block (e.g., ganglion impar block)

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 NE, 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

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 Information

The terms in the section provide operational definitions when they are referenced as requirements in the guideline.

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

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 managementrequirement 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
Complementary conservative management requirement includes ANY of the following:
- Anti-inflammatory medications and analgesics
- Complementary alternative medicine including, but not limited to, acupuncture, chiropractic care, cognitive behavioral or massage therapy

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

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 addressed, stable and have been maximally optimized 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 in anticipation of a planned surgical fusion of the sacroiliac joint only.

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 local anesthetic 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 local anesthetic 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. Concurrent injection in any other areas of the spine is also not appropriate for the same reason.
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.
A maximum of only 2 diagnostic unilateral (same side) intraarticular injections given on two separate occasions are appropriate and medically necessary for the determination of the patient’s candidacy for a surgical fusion (see above).

Diagnostic/therapeutic sacral lateral branch blocks

Injection of local anesthetic alone for diagnostic purposes or anesthetic and steroid for therapeutic purposes into the sacral lateral branches innervating the sacroiliac joint are considered not medically necessary.

Sacral lateral branch radiofrequency ablation by any method is considered not medically necessary.

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
Therapeutic intra/periarticular sacroiliac joint injections in a previously fused sacroiliac joint
Use of corticosteroid with diagnostic intraarticular sacroiliac joint injections
Diagnostic or therapeutic injection (anesthetic and/or steroid) of nerves innervating the sacroiliac joint
Radiofrequency neurolysis for sacroiliac joint pain

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, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain physician. 2021;24(S1):S27-S208
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.
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

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)
64625	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, 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 Information

The terms in the section provide operational definitions when they are referenced as requirements in the guideline.

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

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 managementrequirement includes ANY of the following:
- Anti-inflammatory medications and analgesics
- Complementary alternative medicine including, but not limited to, acupuncture, chiropractic care, cognitive behavioral or massage therapy
Interventional modalities
- Minimally invasive interventional pain procedures such as epidural injections, facet joint procedures, and sympathetic blocks as appropriate

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

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 after a spine surgery (e.g., failed back syndrome)
- Complex regional pain syndrome (CRPS), type I or type II (formerly known as reflex sympathetic dystrophy or causalgia) which meets diagnostic criteria for CRPS as outlined in Regional Sympathetic Nerve Blocks
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 multimodal conservative management
Failed trial of regional sympathetic blocks in the case of CRPS
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 (excludes CRPS)
Documentation of an evaluation by a mental health provider within 6 months of a stimulator trial request (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

A repeat trial is not medically necessary if the initial trial failed, unless certain conditions exist such as failure to guide the percutaneous stimulator lead to the desired level and a repeat trial with a surgically placed lead, device failure prior to the requisite trial period.

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

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

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

History

Status	Review Date	Effective Date	Action
Revised	05/09/2022	11/06/2022* *Not for Anthem Medicaid	Independent Multispecialty Physician Panel (IMPP) review. Epidural injections: For nerve root compression due to herniated disc, MRI/CT must be done within previous 18 months. Selective nerve root block (SNRB): Included a second session for cases requiring evaluation of more than one level. Therapeutic intra-articular facet injection: Added criteria for repeat injection in patients who met criteria for initial injection. Added references.
Revised	05/26/2021	03/13/2022	IMPP review. Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks (DSNRB): allowed more frequent use in newly diagnosed patients, removed imaging requirement in certain circumstances, added epidural abscess as a contraindication; DSNRBs required similar criteria to ESI and limited multilevel and combination DSNRB. Paravertebral Facet Injection/MBB/Neurolysis: limited indefinite use of diagnostic MBB, defined MBB timing with respect to RFN, MBB limited to RFA candidacy, limited open surgical neurolysis, and limited multiple spinal injections. Sacroiliac Joint Injections: limited indefinite use of diagnostic IA injections, disallowed sacral lateral branch blocks and injections in a previously fused joint. Spinal Cord and Nerve Root Stimulators: allowed minimally invasive pain procedures to satisfy conservative management definition, specified timing of mental health evaluation, defined indications for repeat stimulator trial. Updated references. Removed CPT code 64640.
Revised	05/26/2021	11/07/2021	IMPP review. Epidural Injection Procedures and Diagnostic SNRBs: allowed thoracic injections; removed thoracic ESI exclusion. Moved exclusion for radiofrequency neurolysis and CPT codes 64625 and 64640 from Paravertebral Facet Injection/MBB/ Neurolysis section to SI Joint Injections. Spinal Cord and Nerve Root Stimulators: waived surgical opinion requirement for patients with CRPS. Updated references.
Revised	07/08/2020	03/14/2021	IMPP review. Added exclusions: intradiscal spinal injections for chemonucleolysis, injection/infusion of neurolytic substances into the epidural or subarachnoid space, and diagnostic or therapeutic injection (anesthetic and/or steroid) of nerves innervating the SI joint. Added CPT codes 62280, 62281, 62282, 62292, 62324, 62325, 62327, 64451.
Updated	–	01/01/2021	2021 Annual CPT code update: removed 0228T, 0229T, 0230T, 0231T; descriptions changed for 64479, 64480, 64483, 64484.
Revised	10/29/2019	08/16/2020	IMPP review. Modified conservative management requirements to include physical therapy or home therapy plus a complementary modality in alignment with AIM [Carelon] Guidelines for Spine Surgery and Joint Surgery. Epidural Injection Procedures and Diagnostic SNRBs: added statement regarding adherence to procedural best practices established by FDA Safe Use Initiative; clarified intent around requirement for advanced imaging for repeat injections. Paravertebral Facet Injection/Nerve Block/Neurolysis: removed indication for four unilateral MBBs per session; limited use of intraarticular steroid injection to mechanical disruption of a facet synovial cyst. Spinal Cord and Nerve Root Stimulators: new indication for dorsal root ganglion stimulation; clarified exclusions for spinal cord and dorsal root ganglion stimulation.
Revised	–	01/01/2020	2020 Annual CPT code update: added 64625 (paravertebral facet joint injection/nerve block/neurolysis).
Revised	09/12/2018	05/18/2019	IMPP review. All procedures: Reporting of symptom severity expanded to include instrumental ADLs as functional impairment. Epidural Injection Procedures and Diagnostic SNRBs: updated time period of initial advanced imaging; added definition and frequency of repeat therapeutic ESIs; updated maximum number of annual injections; added criteria for subsequent injection after suboptimal initial response. Sacroiliac Joint Injection: lowered threshold in demonstrated pain reduction from the initial injection. Spinal Cord Stimulators: added criteria for revision/removal of spinal cord stimulator; separated criteria of trial stimulation and permanent stimulator implantation; added exclusion of dorsal root ganglion stimulation.
Revised	09/12/2018	01/01/2019	IMPP review. Paravertebral Facet Injection/Nerve Block/Neurolysis: exclusion added for radiofrequency neurolysis for SI joint pain. 2019 Annual CPT code update: added 0228T, 0229T, 0230T, 0231T (epidural injection procedures); added 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64640 (paravertebral facet joint injection/nerve block/neurolysis). HCPCS codes: added C1767, C1820, C1822, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688 (spinal cord stimulators).
Revised	07/11/2018	03/09/2019	IMPP review. Added the General Clinical Guideline.
Revised	12/12/2017	07/01/2018	IMPP review. Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks: added preauthorization exemption for CPT codes 62320 and 62322 when used for post-procedural pain with certain diagnoses; for repeat therapeutic ESIs, clarified initial injection as therapeutic; clarified injection sessions for procedural requirements. Paravertebral Facet Injection/Nerve Block/Neurolysis: increased procedural limitation for diagnostic MBBs; increased procedural limitation for therapeutic intraarticular facet joint injections and clarified requirement for conservative treatment between injections. Added HCPCS code G0260 (SI joint injection).
Created	06/13/2017	11/01/2017	IMPP review. Original effective date.

ARCHIVED Interventional Pain Management 2022-11-06 to 2023-04-08 for commercial/Medicare/non-Anthem Medicaid

Clinical Appropriateness Guidelines

Table of Contents

Description and Application of the Guidelines

General Clinical Guideline

Clinical Appropriateness Framework

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Repeat Diagnostic Intervention

Repeat Therapeutic Intervention

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks

Description

Clinical Indications

General Information

Procedural Best Practices to Prevent Neurologic Complications

Epidural Injections

Procedural Requirements and Restrictions

Therapeutic Epidural Steroid Injection (Interlaminar, Caudal, Transforaminal)

Repeat Therapeutic Epidural Steroid Injection

Diagnostic Selective Nerve Root Block

Contraindications

Exclusions

Selected References

Codes

Paravertebral Facet Injection/Medial Branch Nerve Block/Neurolysis

Description

Clinical Indications

General Information

Patient Requirements

Procedural Requirements

Diagnostic Medial Branch Blocks with Local Anesthetic

Therapeutic Intraarticular Facet Joint Injections

Thermal Medial Branch Radiofrequency Neurotomy

Exclusions

Selected References

Codes

Regional Sympathetic Nerve Block

Description

Clinical Indications

General Information

Complex Regional Pain Syndrome (Type I or Type II)

Exclusions

Selected References

Codes

Sacroiliac Joint Injection

Description

Clinical Indications

General Information

Patient Requirements

Procedural Requirements

Sacroiliac Joint Injections

Diagnostic intraarticular sacroiliac joint injections

Diagnostic/therapeutic sacral lateral branch blocks

Therapeutic intraarticular sacroiliac joint injections

Repeat therapeutic intraarticular sacroiliac joint injections

Ultrasound guidance

Exclusions

Selected References

Codes

Spinal Cord and Nerve Root Stimulators

Description

Clinical Indications

General Information

Spinal Cord Stimulation

Stimulator Trial

Stimulator Implantation (Permanent)

Stimulator Revision or Removal

Dorsal Root Ganglion Stimulation

Exclusions

Selected References

Codes

History

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