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Epidural steroid injections (ESI) for low back pain

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for epidural steroid injections for low back pain. (Effective May 1, 2019, decision support is no longer required for epidural steroid injections for low back pain.)

Sacroiliac joint injections are outside the scope of this policy. Please see related content for policy detailing prior authorization and coverage information.

Coverage

Lumbar epidural steroid injections are covered subject to the indications listed below, and per your plan documents.

Cervical or thoracic epidural steroid injections are covered subject to your plan documents.

Indications that are covered

Epidural steroid injections are covered when they are part of a comprehensive treatment plan and all of the following criteria are met:

Initial injection:

1.

The member has lumbar radicular pain with demonstrable correlation on physical exam and/or

imaging; and

2.

Evaluation has ruled out tumor or other masses as a cause of the pain; and

3.

The pain has been present for at least six weeks; and

4.

The member has failed physical therapy and other conservative treatments (such as exercise,

activity modification, or chiropractic care). Documentation of conservative treatments must correspond to the

current episode of pain (within 6 months).

?

Conservative treatments must include physical therapy (PT), at least 4 visits over a course

of 6 weeks or less. Active muscle conditioning is required as part of physical therapy.

?

Physical therapist's notes must be submitted, or there must be a physician's statement in

the clinical documents that explains why physical therapy is contraindicated.

?

If a member is unable to complete physical therapy due to progressively worsening pain

and disability, documentation in the physical therapists notes demonstrating this is required.

?

The requirement for physical therapy will not be met if there is a failure to complete

prescribed physical therapy for non-clinical reasons.

-or-

5.

Has acute radicular pain with demonstrable correlation on physical exam and/or imaging that

precludes physical therapy (there must be an explicit statement in the clinical documents that explains why

such physical therapy is contraindicated); and

6.

The procedure is performed by an experienced clinician using real-time fluoroscopy monitoring of

contrast material with hard copy or digital documentation of images.

Repeat injections:

1.

Require documentation of 50% pain and/or symptom relief as demonstrated on a Visual Analog

Scale at four weeks post-primary ESI. A pre- and post-Visual Analog Scale must be submitted.

2.

Require a minimum of six weeks between injections;

3.

Are limited to a total of four injections per 12 consecutive months.

4.

Require documentation of member having tried and failed physical therapy during this episode of

pain (within 6 months). .Physical therapy (PT) must include at least 4 visits over a course of 6 weeks or

less. Active muscle conditioning is required as part of physical therapy.

?

Physical therapist's notes must be submitted, or there must be a physician's statement in

the clinical documents that explains why physical therapy is contraindicated.

?

If a member is unable to complete physical therapy due to progressively worsening pain

and disability, documentation in the physical therapists notes demonstrating this is required.

?

The requirement for physical therapy will not be met if there is a failure to complete

prescribed physical therapy for non-clinical reasons.

- or -

5.

Has acute radicular pain with demonstrable correlation on physical exam and/or imaging that

precludes physical therapy (there must be an explicit statement in the clinical documents that explains why

such physical therapy is contraindicated).

Indications that are not covered

Epidural steroid injections are not considered medically necessary and are not covered:

1.

For non-radicular back pain

2.

Without guidance by real-time fluoroscopic imaging

Definitions

Epidural steroid injections may be delivered by the transforaminal, caudal or interlaminar approach.

Episode is defined as a six month consecutive time period corresponding with the member's pain.

Lumbar radicular pain refers to low back pain that radiates to the leg in a radicular pattern consistent with imaging findings.

Codes

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Code 62322 62323

62326

62327

64483 64484

Description 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 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) 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 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) Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

ICD-10 Code M47.20 M47.819 M47.899 M47.9 M48.00 M48.05 M48.061 M48.062 M48.07 M48.08 M48.50XAM48.58XS

Description

Other spondylosis with radiculopathy, site unspecified Spondylosis without myelopathy or radiculopathy, site unspecified Other spondylosis, site unspecified Spondylosis, unspecified Spinal stenosis, site unspecified Spinal stenosis, thoracolumbar region Spinal stenosis, lumbar region without neurogenic claudication Spinal stenosis, lumbar region with neurogenic claudication Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region Collapsed vertebra, not elsewhere classified

M51.15 ? Intervertebral disc disorders with radiculopathy, thoracolumbar, lumbar & lumbosacral regions

M51.17

M51.26,

Other intervertebral disc displacement, lumbar & lumbosacral regions

M51.27

M51.36,

Other intervertebral disc degeneration, lumbar & lumbosacral regions

M51.37

M54.15- Radiculopathy, thoracolumbar, lumbar & lumbosacral regions

M54.17

M54.30- Sciatica

M54.32

M54.40- Lumbago with sciatica

M54.42

M54.5

Lumbago

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M80.08XA- Age-related osteoporosis with current pathological fracture, vertebra(e)

M80.08XS

M80.88XA- Other osteoporosis with current pathological fracture, vertebra(e)

M80.88XS

M84.48XA- Pathological fracture, other site

M84.48XS

M84.58XA- Pathological fracture in neoplastic disease, other specified site

M84.58XS

M84.68XA- Pathological fracture in other disease, other site

M84.68XS

M99.21- Subluxation stenosis of neural canal of cervical, thoracic & lumbar regions

M99.23

M99.31- Osseous stenosis of neural canal of cervical, thoracic & lumbar regions

M99.33

M99.41- Connective tissue stenosis of neural canal of cervical, thoracic & lumbar regions

M99.43

M99.51- Intervertebral disc stenosis of neural canal of cervical, thoracic & lumbar regions

M99.53

M99.61- Osseous and subluxation stenosis of intervertebral foramina of cervical, thoracic & lumbar regions

M99.63

M99.71- Connective tissue and disc stenosis of intervertebral foramina of cervical, thoracic & lumbar regions

M99.73

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical

Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Approved Medical Director Committee 5/18/05, 12/20/10, 10/20/11; Revised 8/3/05, 2/15/06, 5/12/06, 8/8/06, 1/26/11, 4/25/11, 5/1/11, 8/18/11, 10/20/11, 11/15/12 for 1/1/13, 5/1/2015 implementation. 07/29/2013, 7/1/2015, 6/21/16, 1/9/17, 11/30/17, 3/15/18; Annual Review 2/16/06, 8/1/07, 8/1/08, 9/9/09, 11/10/10, 8/2011, 10/2011, 10/11/12, 7/2013, 9/2014, 5/2015, 9/2015, 3/2016, 3/2017, 2/2018, 2/2019

References

1. Benyamin, R. M., Manchikanti, L., Parr, A. T., Diwan, S., Singh, V., Falco, F. J. E., ... Hirsch, J. A. (2012). Systematic review: the effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician, 15, E363-E404.

2. Chou, R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In:UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on January 31, 2019.)

3. Cohen, S. P., White, R. L., Kurihara, C., Larkin, T. M., Chang, A., Griffith, S. R., ... Nguyen, C. (2012). Epidural steroids, etanercept, or saline in subacute sciatica: a multicenter, randomized trial. Annals of Internal Medicine, 156(8), 551-560.

4. ECRI Institute. (2012). Epidural Steroid Injections for Treating Lumbar Radiculopathy. Plymouth Meeting, PA: ECRI Institute.

5. Goertz, M., Thorson, D., Bonsell, J., Bonte, B., Campbell, R., Haake, B., ... Timming, R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.

6. Hayes, Inc. Hayes Medical Technology Directory Report. Epidural Steroid Injections for Low Back Pain and Sciatica. Lansdale, PA: Hayes, Inc.; January, 2013. Reviewed January, 2017.

7. Institute for Clinical Systems Improvement, Health Care Guideline: Adult Acute and Subacute Low Back Pain, Sixteenth Edition, March 2018

8. Washington State Health Care Authority. (2011). Health Technology Assessment: Spinal Injections Updated Final Evidence Report. Reviewed February 2016. Retrieved from

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