HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-189-018
Topic:
Epidural Steroid Injections
Section:
Surgery
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Transforaminal epidural steroid injection (ESI) is a therapeutic injection of contrast (absent allergy to contrast) performed at a single or multiple spinal levels, followed by the introduction of a corticosteroid and possibly a local anesthetic by inserting a needle into the neuroforamen under fluoroscopic or computed tomography (CT) guidance.

Selective Nerve Root Block (SNRB) is a diagnostic injection of contrast (absent allergy to contrast) of a single nerve root to assist with surgical planning, followed by the introduction of a local anesthetic by inserting a needle into the neuroforamen under fluoroscopic or computed tomography (CT) guidance. SNRB’s are erroneously referred to as Transforaminal Epidural Steroid Injection (TFESI), although technically SNRB’s involve the introduction of anesthetic only and are used for diagnostic purposes.

Interlaminar epidural steroid injection (ESI) is an injection of contrast (absent allergy to contrast), followed by the introduction of a corticosteroid and possibly a local anesthetic into the epidural space of the spine either through a paramedian or midline interlaminar approach under fluoroscopic guidance.

Caudal epidural steroid injection (ESI) is an injection of contrast (absent allergy to contrast), followed by the introduction of corticosteroids and possibly a local anesthetic into the epidural space of the spine by inserting a needle through the sacral hiatus under fluoroscopic guidance into the epidural space at the sacral canal.

Radiculopathy, for the purpose of this policy, is defined as the presence of pain, dysaethesia(s), or paraesthesia(s) reported by the individual in a specified dermatomal distribution of an involved named spainl root(s) causing significant functional limitations (i.e., diminished quality of life and impaired, age-appropriate activities of daily living), and

EITHER of the following:

  • Documentation of ONE or MORE of the following, concordant with nerve root compression of the involved named spinal root(s) demonstrated on a detailed neurologic examination within the prior three (3) months:
    • Loss of strength of specific named muscle(s) or myotomal distribution(s)
    • Altered sensation to light touch, pressure, pin prick or temperature in the
    • sensory distribution
    • Diminished, absent or asymmetric reflex(es)
  • Documentation of EITHER of the following performed within the prior 12 months:
    • A concordant radiologist’s interpretation of an advanced diagnostic imaging study (MRI or CT) of the spine demonstrating compression of the involved named spinal nerve root(s)
    • Electrodiagnostic studies (EMG/NCV’s) diagnostic of nerve root compression of the involved named spinal nerve root(s).

Radicular pain is pain which radiates to the lower extremity along the course of a spinal nerve root, typically resulting from compression, inflammation and/or injury to the nerve root.

Radiculitis is defined, for the purpose of this policy, as radicular pain without objective neurological findings on physical examination.

Spinal stenosis refers to the narrowing of the spinal canal usually due to spinal degeneration that occurs with aging. It may also be the result of spinal disc herniation, osteoarthritis, or a tumor. Lumbar spinal stenosis results in low back pain as well as pain or abnormal sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel control. Neurogenic claudication is often a clinical condition that results from spinal stenosis.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Selective Nerve Root Block (SNRB)

Diagnostic SNRB, performed at a single nerve root, involving the introduction of anesthetic only, may be considered medically necessary when attempting to establish the diagnosis of radicular pain (including radiculitis) or radiculopathy when the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological studies and electrodiagnostic studies) in the following clinical situations:

·         Physical signs and symptoms differ from that found on imaging studies; or

·         Clinical evidence of multi-level nerve root pathology; or

·         Clinical presentation is suggestive, but not typical for both nerve root and peripheral nerve or joint disease involvement; or

·         Clinical findings are consistent with radiculopathy in a dermatomal distribution, but the imaging studies do not corroborate the findings (i.e. positive straight leg raise test); or

·         Individual has had previous spinal surgery; or

·         Purposes of surgical planning

A second SNRB may be considered medically necessary when the following criteria are met:

  • Evidence of multilevel pathology; and
  • It has been at least two (2) weeks since the prior injection

A second/repeat selective nerve root block is considered not medically necessary for EITHER of the following:

  • Inadequate response to the first block, as determined by the injectate utilized; or
  • Absence of multilevel pathology when the first injection is performed under fluoroscopy/CT guidance using contrast

Diagnostic and therapeutic SNRBs are considered not medically necessary for ANY other indication.


Epidural Steroid Injections (Transforaminal, Interlaminar, or Caudal)

ESI may be considered medically necessary for ANY of the following indications when criteria are met:

·         Treatment of presumed radiculopathy when there has been failure of at least six (6) weeks of conservative treatment (i.e., exercise, physical methods including physical therapy, chiropractic care, nonsteroidal anti-inflammatory drugs (NSAID’s), muscle relaxants); or

·         Treatment of presumed radiculitis or radicular pain when ALL of the following are met:

o    Radicular pain, with or without motor weakness, which follows a specified dermatomal distribution of an involved named spinal root(s); and

o    Positive straight leg raise, crossed leg raise, and/or Spurling’s; and

o    Failure of at least six (6) weeks of conservative treatment (i.e., exercise, physical methods including physical therapy, chiropractic care, NSAIDS, muscle relaxants).

Transforaminal ESI, when performed in addition to an intra-articular facet joint injection with synovial cyst aspiration, may be considered medically necessary when the following criteria are met:

·         Advanced diagnostic imaging studies (e.g., MRI CT, CT myelogram) confirm compression or displacement of the corresponding nerve root by a facet joint synovial cyst

·         Clinical correlation with the individual’s signs and symptoms of radicular pain or radiculopathy, based on history and physical examination.

ESI may be considered medically necessary as an initial trial when there is evidence of symptomatic spinal stenosis and ALL of the following criteria are met:

·         Diagnostic evaluation has ruled out other potential causes of pain; and

·         MRI or CT with or without Myelography within the past twelve (12) months demonstrates severe spinal stenosis at the level to be treated; and

·         Significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living; and

·         Failure of at least four (4) weeks of conservative treatment (i.e., exercise physical methods including physical therapy, chiropractic care, NSAIDS, muscle relaxants)

A repeat ESI may be considered medically necessary when at least two (2) of the following criteria are met for two (2) or more week’s duration:

·         50% or greater pain relief; or

·         Increase in the level of function/physical activity (i.e., return to work) ; or

·         Reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic case

ESI is considered not medically necessary for ALL of the following:

·         When performed without imaging guidance (i.e., CT, fluoroscopy)

·         Transforaminal ESI performed at more than two (2) nerve root levels during the same session/procedure

·         An interlaminar ESI, performed at more than a single level during the same session/procedure

·         ESI administered in the same region as other spinal injections on the same day of service

·         Performed in isolation (i.e., without the individual participating in an active rehabilitation program/home exercise program/functional restoration program)

·         Repeating ESI ‘s more frequently than every seven (7) days

·         More than three (3) spidural steroid injections per episode of pain

·         More than four (4) ESI’s per region, per yaer

·         Axial spinal pain (i.e., absence of radiculopathy, myelopathy, myeloradiculopathy)

·         A caudal ESI for levels above L4-L5 without supporting clinical rationale for use of alternative approaches (i.e., translaminar, transforaminal)

ESI performed with ultrasound guidance is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. 

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Related Policies

Refer to medical policy Z-61, Facet Joint Injections/Medial Branch Blocks, for additional information.

Refer to medical policy A-10, Pain Control, for additional information.


Place of Service: Outpatient



The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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