EPIDURAL STEROID AND FACET INJECTIONS FOR SPINAL PAIN

Transcription

1 CLINICAL POLICY EPIDURAL STEROID AND FACET INJECTIONS FOR SPINAL PAIN Policy Number: PAIN T2 Effective Date: December 1, 2015 Table of Contents CONDITIONS OF COVERAGE... BENEFIT CONSIDERATIONS.. COVERAGE RATIONALE.. APPLICABLE CODES. DESCRIPTION OF SERVICE... CLINICAL EVIDENCE... U.S. FOOD AND DRUG ADMINISTRATION... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Policy History Revision Information The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Page Related Policies: Ablative Treatment for Spinal Pain Occipital Neuralgia and Headache Treatment Applicable Lines of Business/Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership General benefits package Yes - Office No - Outpatient No - Office 1 Yes - Outpatient No 1 Office, Outpatient 1 Precertification with review by a Medical Director is required for CPT codes 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T and 0231T 1

2 BENEFIT CONSIDERATIONS Essential Health Benefits for Individual and Small Group: For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits ( EHBs ). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this guideline, it is important to refer to the member specific benefit document to determine benefit coverage. COVERAGE RATIONALE Epidural steroid injections in this policy apply to the lumbar spine only. This section does not address cervical injections. The facet joint injections section of this policy addresses multiple sites, and is not limited to the lumbar spine. Oxford will provide coverage for epidural steroid and facet joint injections as outlined below and further subject to the CPT and ICD-9 diagnosis codes listed in the Payment Guidelines section. The use of ultrasound guidance for epidural steroid injection(s) and facet joint injection(s) is unproven and not medically necessary. There is insufficient clinical evidence regarding its safety and/or efficacy in published peer-reviewed medical literature. The available published evidence for ultrasound guidance for facet and epidural injections is limited to a small feasibility study and a cadaver study. Epidural Steroid Injections Epidural steroid injection proven and medically necessary when used for the treatment of acute and sub-acute sciatica or radicular pain of the low back caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae. Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: o o The pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and The pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy Epidural steroid injection is unproven and not medically necessary for all other indications of the lumbar spine. There is a lack of evidence from randomized controlled trials indicating that epidural steroid injections effectively treat patients with lumbar pain not associated with sciatica or radicular pain. Note: This policy does not apply to obstetrical epidural anesthesia utilized during labor and delivery. Facet Joint Injections Diagnostic facet joint injection and/or facet nerve block (e.g. medial branch block) is proven and medically necessary when used to localize the source of pain to the facet joint in persons with spinal pain. 2

3 Therapeutic facet joint injection is unproven and not medically necessary for the treatment of chronic spinal pain. Clinical evidence about the very existence of facet joint syndrome is conflicting, and evidence from studies is inadequate regarding the superiority of periodic facet joint injections compared to placebo in relieving chronic spinal pain (pain lasting more than 3 months). Additional Information Facet joint injection, as a diagnostic procedure prior to radiofrequency ablation, is not recommended in patients with: Neurologic abnormalities More than one pain syndrome Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome Previous spinal surgery at the clinically suspected levels APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. Non-Reimbursable CPT Codes (Precertification with Medical Director Review is required) CPT Code (Unproven/Not Medically Necessary) 0213T 0214T 0215T 0216T 0217T 0218T 0230T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 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) 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) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 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) 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) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 3

4 CPT Code (Unproven/Not Medically Necessary) 0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) CPT is a registered trademark of the American Medical Association. Reimbursable CPT Codes: Facet Joint Injections CPT Code: Facet Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 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) 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) 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 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) 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) CPT is a registered trademark of the American Medical Association. Reimbursable CPT Codes: Epidural Steroid Injections CPT Code: Epidural Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Injection, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 4

5 CPT Code: Epidural Injection, anesthetic agent 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) CPT is a registered trademark of the American Medical Association. Reimbursable ICD-9 Diagnosis Codes (Discontinued 10/01/15) The following list of codes is provided for reference purposes only. Effective October 1, 2015, the Centers for Medicare & Medicaid Services (CMS) implemented ICD-10-CM (diagnoses) and ICD- 10-PCS (inpatient procedures), replacing the ICD-9-CM diagnosis and procedure code sets. ICD-9 codes will not be accepted for services provided on or after October 1, ICD-9 Code: Facet Discontinued 10/01/ Unspecified inflammatory spondylopathy Cervical spondylosis without myelopathy Cervical spondylosis with myelopathy Thoracic spondylosis without myelopathy Lumbosacral spondylosis without myelopathy Spondylosis with myelopathy, thoracic Spondylosis with myelopathy, lumbar Spondylosis of unspecified site without mention of myelopathy Displacement of lumbar intervertebral disc without myelopathy Postlaminectomy syndrome, cervical Postlaminectomy syndrome, thoracic Postlaminectomy syndrome, lumbar Pathologic fracture of vertebrae Scoliosis (and kyphoscoliosis), idiopathic Acquired spondylolisthesis Closed fracture of cervical vertebra, unspecified level without mention of spinal cord injury Closed fracture of first cervical vertebra without mention of spinal cord injury Closed fracture of second cervical vertebra without mention of spinal cord injury Closed fracture of third cervical vertebra without mention of spinal cord injury Closed fracture of fourth cervical vertebra without mention of spinal cord injury Closed fracture of fifth cervical vertebra without mention of spinal cord injury Closed fracture of sixth cervical vertebra without mention of spinal cord injury Closed fracture of seventh cervical vertebra without mention of spinal cord injury Closed fracture of multiple cervical vertebrae without mention of spinal cord injury Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury Closed fracture of lumbar vertebra without mention of spinal cord injury Fracture of vertebral column without mention of spinal cord injury ; Sacrum and coccyx, closed 5

6 ICD-9 Code: Facet Discontinued 10/01/ Fracture of vertebral column without mention of spinal cord injury; Unspecified, closed ICD-9 Code: Epidural Discontinued 10/01/ Unspecified reflex sympathetic dystrophy Reflex sympathetic dystrophy of the lower limb Reflex sympathetic dystrophy of other specified site Lumbosacral plexus lesions Lumbosacral root lesions, not elsewhere classified Mononeuritis of lower limb and unspecified site (Incomplete code - additional digit required) Causalgia of lower limb Other mononeuritis of lower limb Mononeuritis of lower limb, unspecified Mononeuritis of unspecified site Lumbosacral spondylosis without myelopathy Spondylosis with myelopathy, lumbar Displacement of lumbar intervertebral disc without myelopathy Displacement of intervertebral disc, site unspecified, without myelopathy Schmorl's nodes, lumbar Degeneration of thoracic or thoracolumbar intervertebral disc Degeneration of lumbar or lumbosacral intervertebral disc Intervertebral lumbar disc disorder with myelopathy, lumbar Postlaminectomy syndrome, lumbar Spinal stenosis, lumbar, without neurogenic claudication Spinal stenosis, lumbar, with neurogenic claudication Spinal stenosis, other other than cervical Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Disorders of sacrum Acquired spondylolisthesis Closed fracture of lumbar vertebra without mention of spinal cord injury Injury to dorsal nerve root Injury to lumbar nerve root Injury to sacral nerve root Injury to lumbosacral plexus Injury to sciatic nerve Reimbursable ICD-10 Codes () ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures) must be used to report services provided on or after October 1, ICD-10 codes will not be accepted for services provided prior to October 1, ICD-10 Code: Epidural E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy 6

7 ICD-10 Code: Epidural E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E13.41 Other specified diabetes mellitus with diabetic mononeuropathy G54.1 Lumbosacral plexus disorders G54.4 Lumbosacral root disorders, not elsewhere classified G57.00 Lesion of sciatic nerve, unspecified lower limb G57.01 Lesion of sciatic nerve, right lower limb G57.02 Lesion of sciatic nerve, left lower limb G57.70 Causalgia of unspecified lower limb G57.71 Causalgia of right lower limb G57.72 Causalgia of left lower limb G57.80 Other specified mononeuropathies of unspecified lower limb G57.81 Other specified mononeuropathies of right lower limb G57.82 Other specified mononeuropathies of left lower limb G57.90 Unspecified mononeuropathy of unspecified lower limb G57.91 Unspecified mononeuropathy of right lower limb G57.92 Unspecified mononeuropathy of left lower limb G58.8 Other specified mononeuropathies G58.9 Mononeuropathy, unspecified G59 Mononeuropathy in diseases classified elsewhere G90.50 Complex al pain syndrome I, unspecified G Complex al pain syndrome I of right lower limb G Complex al pain syndrome I of left lower limb G Complex al pain syndrome I of lower limb, bilateral G Complex al pain syndrome I of unspecified lower limb G90.59 Complex al pain syndrome I of other specified site M43.00 Spondylolysis, site unspecified M43.01 Spondylolysis, occipito-atlanto-axial M43.02 Spondylolysis, cervical M43.03 Spondylolysis, cervicothoracic M43.04 Spondylolysis, thoracic M43.05 Spondylolysis, thoracolumbar M43.06 Spondylolysis, lumbar M43.07 Spondylolysis, lumbosacral M43.08 Spondylolysis, sacral and sacrococcygeal M43.09 Spondylolysis, multiple sites in spine M43.10 Spondylolisthesis, site unspecified M43.11 Spondylolisthesis, occipito-atlanto-axial M43.12 Spondylolisthesis, cervical M43.13 Spondylolisthesis, cervicothoracic M43.14 Spondylolisthesis, thoracic M43.15 Spondylolisthesis, thoracolumbar M43.16 Spondylolisthesis, lumbar M43.17 Spondylolisthesis, lumbosacral M43.18 Spondylolisthesis, sacral and sacrococcygeal M43.19 Spondylolisthesis, multiple sites in spine M43.27 Fusion of spine, lumbosacral M43.28 Fusion of spine, sacral and sacrococcygeal M47.16 Other spondylosis with myelopathy, lumbar M47.26 Other spondylosis with radiculopathy, lumbar 7

8 ICD-10 Code: Epidural M47.27 Other spondylosis with radiculopathy, lumbosacral M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal M Spondylosis without myelopathy or radiculopathy, lumbar M Spondylosis without myelopathy or radiculopathy, M lumbosacral Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal M Other spondylosis, lumbar M Other spondylosis, lumbosacral M Other spondylosis, sacral and sacrococcygeal M48.00 Spinal Stenosis, site unspecified M48.06 Spinal stenosis, lumbar M48.07 Spinal stenosis, lumbosacral M48.08 Spinal stenosis, sacral and sacrococcygeal M51.06 Intervertebral disc disorders with myelopathy, lumbar M51.14 M51.15 M51.16 M51.17 Intervertebral disc disorders with radiculopathy, thoracic Intervertebral disc disorders with radiculopathy, thoracolumbar Intervertebral disc disorders with radiculopathy, lumbar Intervertebral disc disorders with radiculopathy, lumbosacral M51.26 Other intervertebral disc displacement, lumbar M51.27 Other intervertebral disc displacement, lumbosacral M51.34 Other intervertebral disc degeneration, thoracic M51.35 Other intervertebral disc degeneration, thoracolumbar M51.36 Other intervertebral disc degeneration, lumbar M51.37 Other intervertebral disc degeneration, lumbosacral M51.46 Schmorl's nodes, lumbar M51.47 Schmorl's nodes, lumbosacral M51.9 Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder M53.2X7 Spinal instabilities, lumbosacral M53.2X8 Spinal instabilities, sacral and sacrococcygeal M53.3 Sacrococcygeal disorders, not elsewhere classified M53.86 Other specified dorsopathies, lumbar M53.87 Other specified dorsopathies, lumbosacral M53.88 Other specified dorsopathies, sacral and sacrococcygeal M54.14 Radiculopathy, thoracic M54.15 Radiculopathy, thoracolumbar M54.16 Radiculopathy, lumbar M54.17 Radiculopathy, lumbosacral M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M54.32 Sciatica, left side M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M96.1 Postlaminectomy syndrome, not elsewhere classified 8

9 ICD-10 Code: Epidural M99.23 Subluxation stenosis of neural canal of lumbar M99.24 Subluxation stenosis of neural canal of sacral M99.25 Subluxation stenosis of neural canal of pelvic M99.26 Subluxation stenosis of neural canal of lower extremity M99.27 Subluxation stenosis of neural canal of upper extremity M99.28 Subluxation stenosis of neural canal of rib cage M99.29 Subluxation stenosis of neural canal of abdomen and other s M99.33 Osseous stenosis of neural canal of lumbar M99.34 Osseous stenosis of neural canal of sacral M99.35 Osseous stenosis of neural canal of pelvic M99.36 Osseous stenosis of neural canal of lower extremity M99.37 Osseous stenosis of neural canal of upper extremity M99.38 Osseous stenosis of neural canal of rib cage M99.39 Osseous stenosis of neural canal of abdomen and other s M99.43 Connective tissue stenosis of neural canal of lumbar M99.44 Connective tissue stenosis of neural canal of sacral M99.45 Connective tissue stenosis of neural canal of pelvic M99.46 Connective tissue stenosis of neural canal of lower extremity M99.47 Connective tissue stenosis of neural canal of upper extremity M99.48 Connective tissue stenosis of neural canal of rib cage M99.49 Connective tissue stenosis of neural canal of abdomen and other s M99.53 Intervertebral disc stenosis of neural canal of lumbar M99.54 Intervertebral disc stenosis of neural canal of sacral M99.55 Intervertebral disc stenosis of neural canal of pelvic M99.56 Intervertebral disc stenosis of neural canal of lower extremity M99.57 Intervertebral disc stenosis of neural canal of upper extremity M99.58 Intervertebral disc stenosis of neural canal of rib cage M99.59 Intervertebral disc stenosis of neural canal of abdomen and other s M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar M99.64 Osseous and subluxation stenosis of intervertebral foramina of sacral M99.65 Osseous and subluxation stenosis of intervertebral foramina of pelvic M99.66 Osseous and subluxation stenosis of intervertebral foramina of lower extremity M99.67 Osseous and subluxation stenosis of intervertebral foramina of upper extremity M99.68 Osseous and subluxation stenosis of intervertebral foramina of rib cage M99.69 Osseous and subluxation stenosis of intervertebral foramina of abdomen and other s M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar M99.74 Connective tissue and disc stenosis of intervertebral foramina of sacral M99.75 Connective tissue and disc stenosis of intervertebral foramina of pelvic M99.76 Connective tissue and disc stenosis of intervertebral foramina of lower extremity 9

10 ICD-10 Code: Epidural M99.77 M99.78 M99.79 S24.2XXA S32.000A S32.001A S32.002A S32.008A S32.009A S32.010A S32.011A S32.012A S32.018A S32.019A S32.020A S32.021A S32.022A S32.028A S32.029A S32.030A S32.031A S32.032A S32.038A S32.039A S32.040A S32.041A S32.042A Connective tissue and disc stenosis of intervertebral foramina of upper extremity Connective tissue and disc stenosis of intervertebral foramina of rib cage Connective tissue and disc stenosis of intervertebral foramina of abdomen and other s Injury of nerve root of thoracic spine, initial encounter Wedge compression fracture of unspecified lumbar vertebra, initial Stable burst fracture of unspecified lumbar vertebra, initial Unstable burst fracture of unspecified lumbar vertebra, initial Other fracture of unspecified lumbar vertebra, initial Unspecified fracture of unspecified lumbar vertebra, initial Wedge compression fracture of first lumbar vertebra, initial Stable burst fracture of first lumbar vertebra, initial encounter for Unstable burst fracture of first lumbar vertebra, initial Other fracture of first lumbar vertebra, initial encounter for Unspecified fracture of first lumbar vertebra, initial encounter for Wedge compression fracture of second lumbar vertebra, initial Stable burst fracture of second lumbar vertebra, initial Unstable burst fracture of second lumbar vertebra, initial Other fracture of second lumbar vertebra, initial encounter for Unspecified fracture of second lumbar vertebra, initial Wedge compression fracture of third lumbar vertebra, initial Stable burst fracture of third lumbar vertebra, initial encounter for Unstable burst fracture of third lumbar vertebra, initial Other fracture of third lumbar vertebra, initial encounter for Unspecified fracture of third lumbar vertebra, initial encounter for Wedge compression fracture of fourth lumbar vertebra, initial Stable burst fracture of fourth lumbar vertebra, initial Unstable burst fracture of fourth lumbar vertebra, initial 10

11 ICD-10 Code: Epidural S32.048A S32.049A S32.050A S32.051A S32.052A S32.058A S32.059A S34.21XA S34.22XA S34.4XXA S74.00XA S74.01XA S74.02XA Other fracture of fourth lumbar vertebra, initial encounter for Unspecified fracture of fourth lumbar vertebra, initial Wedge compression fracture of fifth lumbar vertebra, initial Stable burst fracture of fifth lumbar vertebra, initial encounter for Unstable burst fracture of fifth lumbar vertebra, initial Other fracture of fifth lumbar vertebra, initial encounter for Unspecified fracture of fifth lumbar vertebra, initial encounter for Injury of nerve root of lumbar spine, initial encounter Injury of nerve root of sacral spine, initial encounter Injury of lumbosacral plexus, initial encounter Injury of sciatic nerve at hip and thigh level, unspecified leg, initial encounter Injury of sciatic nerve at hip and thigh level, right leg, initial encounter Injury of sciatic nerve at hip and thigh level, left leg, initial encounter ICD-10 Code: Facet M Juvenile idiopathic scoliosis, cervical M Juvenile idiopathic scoliosis, cervicothoracic M Juvenile idiopathic scoliosis, thoracic M Juvenile idiopathic scoliosis, thoracolumbar M Juvenile idiopathic scoliosis, lumbar M Juvenile idiopathic scoliosis, lumbosacral M Juvenile idiopathic scoliosis, site unspecified M Adolescent idiopathic scoliosis, cervical M Adolescent idiopathic scoliosis, cervicothoracic M Adolescent idiopathic scoliosis, thoracic M Adolescent idiopathic scoliosis, thoracolumbar M Adolescent idiopathic scoliosis, lumbar M Adolescent idiopathic scoliosis, lumbosacral M Adolescent idiopathic scoliosis, site unspecified M41.20 Other idiopathic scoliosis, site unspecified M41.22 Other idiopathic scoliosis, cervical M41.23 Other idiopathic scoliosis, cervicothoracic M41.24 Other idiopathic scoliosis, thoracic M41.25 Other idiopathic scoliosis, thoracolumbar M41.26 Other idiopathic scoliosis, lumbar M41.27 Other idiopathic scoliosis, lumbosacral M43.00 Spondylolysis, site unspecified M43.01 Spondylolysis, occipito-atlanto-axial M43.02 Spondylolysis, cervical M43.03 Spondylolysis, cervicothoracic M43.04 Spondylolysis, thoracic 11

12 ICD-10 Code: Facet M43.05 Spondylolysis, thoracolumbar M43.06 Spondylolysis, lumbar M43.07 Spondylolysis, lumbosacral M43.08 Spondylolysis, sacral and sacrococcygeal M43.09 Spondylolysis, multiple sites in spine M43.10 Spondylolisthesis, site unspecified M43.11 Spondylolisthesis, occipito-atlanto-axial M43.12 Spondylolisthesis, cervical M43.13 Spondylolisthesis, cervicothoracic M43.14 Spondylolisthesis, thoracic M43.15 Spondylolisthesis, thoracolumbar M43.16 Spondylolisthesis, lumbar M43.17 Spondylolisthesis, lumbosacral M43.18 Spondylolisthesis, sacral and sacrococcygeal M43.19 Spondylolisthesis, multiple sites in spine M46.90 Unspecified inflammatory spondylopathy, site unspecified M46.91 Unspecified inflammatory spondylopathy, occipito-atlantoaxial M46.92 Unspecified inflammatory spondylopathy, cervical M46.93 Unspecified inflammatory spondylopathy, cervicothoracic M46.94 Unspecified inflammatory spondylopathy, thoracic M46.95 Unspecified inflammatory spondylopathy, thoracolumbar M46.96 Unspecified inflammatory spondylopathy, lumbar M46.97 Unspecified inflammatory spondylopathy, lumbosacral M46.98 Unspecified inflammatory spondylopathy, sacral and sacrococcygeal M46.99 Unspecified inflammatory spondylopathy, multiple sites in spine M Anterior spinal artery compression syndromes, occipitoatlanto-axial M Anterior spinal artery compression syndromes, cervical M Anterior spinal artery compression syndromes, cervicothoracic M Anterior spinal artery compression syndromes, thoracic M Anterior spinal artery compression syndromes, thoracolumbar M Anterior spinal artery compression syndromes, lumbar M Anterior spinal artery compression syndromes, site unspecified M Vertebral artery compression syndromes, occipito-atlantoaxial M Vertebral artery compression syndromes, cervical M Vertebral artery compression syndromes, site unspecified M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial M47.12 Other spondylosis with myelopathy, cervical M47.13 Other spondylosis with myelopathy, cervicothoracic M47.14 Other spondylosis with myelopathy, thoracic M47.15 Other spondylosis with myelopathy, thoracolumbar M47.16 Other spondylosis with myelopathy, lumbar 12

13 ICD-10 Code: Facet M47.20 Other spondylosis with radiculopathy, site unspecified M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial M47.22 Other spondylosis with radiculopathy, cervical M47.23 Other spondylosis with radiculopathy, cervicothoracic M47.24 Other spondylosis with radiculopathy, thoracic M47.25 Other spondylosis with radiculopathy, thoracolumbar M47.26 Other spondylosis with radiculopathy, lumbar M47.27 Other spondylosis with radiculopathy, lumbosacral M47.28 M M M M M M M M M Other spondylosis with radiculopathy, sacral and sacrococcygeal Spondylosis without myelopathy or radiculopathy, occipitoatlanto-axial Spondylosis without myelopathy or radiculopathy, cervical Spondylosis without myelopathy or radiculopathy, cervicothoracic Spondylosis without myelopathy or radiculopathy, thoracic Spondylosis without myelopathy or radiculopathy, thoracolumbar Spondylosis without myelopathy or radiculopathy, lumbar Spondylosis without myelopathy or radiculopathy, lumbosacral Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal Spondylosis without myelopathy or radiculopathy, site unspecified M Other spondylosis, occipito-atlanto-axial M Other spondylosis, cervical M Other spondylosis, cervicothoracic M Other spondylosis, thoracic M Other spondylosis, thoracolumbar M Other spondylosis, lumbar M Other spondylosis, lumbosacral M Other spondylosis, sacral and sacrococcygeal M Other spondylosis, site unspecified M47.9 Spondylosis, unspecified M48.50XA M48.51XA M48.52XA M48.53XA M48.54XA M48.55XA M48.56XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture Collapsed vertebra, not elsewhere classified, occipito-atlantoaxial, initial encounter for fracture Collapsed vertebra, not elsewhere classified, cervical, initial encounter for fracture Collapsed vertebra, not elsewhere classified, cervicothoracic, initial encounter for fracture Collapsed vertebra, not elsewhere classified, thoracic, initial encounter for fracture Collapsed vertebra, not elsewhere classified, thoracolumbar, initial encounter for fracture Collapsed vertebra, not elsewhere classified, lumbar, initial encounter for fracture 13

14 ICD-10 Code: Facet M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral, initial encounter for fracture M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal, initial encounter for fracture M51.26 Other intervertebral disc displacement, lumbar M51.27 Other intervertebral disc displacement, lumbosacral M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M84.48XA Pathological fracture, other site, initial encounter for fracture M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture M96.1 Postlaminectomy syndrome, not elsewhere classified S12.000A Unspecified displaced fracture of first cervical vertebra, initial S12.001A Unspecified nondisplaced fracture of first cervical vertebra, initial S12.01XA Stable burst fracture of first cervical vertebra, initial encounter for S12.02XA Unstable burst fracture of first cervical vertebra, initial S12.030A Displaced posterior arch fracture of first cervical vertebra, initial S12.031A Nondisplaced posterior arch fracture of first cervical vertebra, initial S12.040A Displaced lateral mass fracture of first cervical vertebra, initial S12.041A Nondisplaced lateral mass fracture of first cervical vertebra, initial S12.090A Other displaced fracture of first cervical vertebra, initial S12.091A Other nondisplaced fracture of first cervical vertebra, initial S12.100A Unspecified displaced fracture of second cervical vertebra, initial S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial S12.110A Anterior displaced Type II dens fracture, initial encounter for S12.111A Posterior displaced Type II dens fracture, initial encounter for S12.112A Nondisplaced Type II dens fracture, initial encounter for S12.120A Other displaced dens fracture, initial encounter for closed fracture S12.121A Other nondisplaced dens fracture, initial encounter for closed fracture S12.130A Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initial S12.131A Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial 14

15 ICD-10 Code: Facet S12.14XA S12.150A S12.151A S12.190A S12.191A S12.200A S12.201A S12.230A S12.231A S12.24XA S12.250A S12.251A S12.290A S12.291A S12.300A S12.301A S12.330A S12.331A S12.34XA S12.350A S12.351A S12.390A S12.391A S12.400A S12.401A S12.430A S12.431A Type III traumatic spondylolisthesis of second cervical vertebra, initial Other traumatic displaced spondylolisthesis of second cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial Other displaced fracture of second cervical vertebra, initial Other nondisplaced fracture of second cervical vertebra, initial Unspecified displaced fracture of third cervical vertebra, initial Unspecified nondisplaced fracture of third cervical vertebra, initial Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial Type III traumatic spondylolisthesis of third cervical vertebra, initial Other traumatic displaced spondylolisthesis of third cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial Other displaced fracture of third cervical vertebra, initial Other nondisplaced fracture of third cervical vertebra, initial Unspecified displaced fracture of fourth cervical vertebra, initial Unspecified nondisplaced fracture of fourth cervical vertebra, initial Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initial Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial Type III traumatic spondylolisthesis of fourth cervical vertebra, initial Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial Other displaced fracture of fourth cervical vertebra, initial Other nondisplaced fracture of fourth cervical vertebra, initial Unspecified displaced fracture of fifth cervical vertebra, initial Unspecified nondisplaced fracture of fifth cervical vertebra, initial Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial 15

16 ICD-10 Code: Facet S12.44XA S12.450A S12.451A S12.490A S12.491A S12.500A S12.501A S12.530A S12.531A S12.54XA S12.550A S12.551A S12.590A S12.591A S12.600A S12.601A S12.630A S12.631A S12.64XA S12.650A S12.651A S12.690A S12.691A S12.9XXA S22.000A S22.001A S22.002A Type III traumatic spondylolisthesis of fifth cervical vertebra, initial Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial Other displaced fracture of fifth cervical vertebra, initial Other nondisplaced fracture of fifth cervical vertebra, initial Unspecified displaced fracture of sixth cervical vertebra, initial Unspecified nondisplaced fracture of sixth cervical vertebra, initial Unspecified traumatic displaced spondylolisthesis of sixth cervical vertebra, initial Unspecified traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial Type III traumatic spondylolisthesis of sixth cervical vertebra, initial Other traumatic displaced spondylolisthesis of sixth cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of sixth cervical vertebra, initial Other displaced fracture of sixth cervical vertebra, initial Other nondisplaced fracture of sixth cervical vertebra, initial Unspecified displaced fracture of seventh cervical vertebra, initial Unspecified nondisplaced fracture of seventh cervical vertebra, initial Unspecified traumatic displaced spondylolisthesis of seventh cervical vertebra, initial Unspecified traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial Type III traumatic spondylolisthesis of seventh cervical vertebra, initial Other traumatic displaced spondylolisthesis of seventh cervical vertebra, initial Other traumatic nondisplaced spondylolisthesis of seventh cervical vertebra, initial Other displaced fracture of seventh cervical vertebra, initial Other nondisplaced fracture of seventh cervical vertebra, initial Fracture of neck, unspecified, initial encounter Wedge compression fracture of unspecified thoracic vertebra, initial Stable burst fracture of unspecified thoracic vertebra, initial Unstable burst fracture of unspecified thoracic vertebra, initial 16

17 ICD-10 Code: Facet S22.008A S22.009A S22.010A S22.011A S22.012A S22.018A S22.019A S22.020A S22.021A S22.022A S22.028A S22.029A S22.030A S22.031A S22.032A S22.038A S22.039A S22.040A S22.041A S22.042A S22.048A S22.049A S22.050A S22.051A S22.052A S22.058A S22.059A Other fracture of unspecified thoracic vertebra, initial Unspecified fracture of unspecified thoracic vertebra, initial Wedge compression fracture of first thoracic vertebra, initial Stable burst fracture of first thoracic vertebra, initial Unstable burst fracture of first thoracic vertebra, initial Other fracture of first thoracic vertebra, initial encounter for Unspecified fracture of first thoracic vertebra, initial encounter for Wedge compression fracture of second thoracic vertebra, initial Stable burst fracture of second thoracic vertebra, initial Unstable burst fracture of second thoracic vertebra, initial Other fracture of second thoracic vertebra, initial encounter for Unspecified fracture of second thoracic vertebra, initial Wedge compression fracture of third thoracic vertebra, initial Stable burst fracture of third thoracic vertebra, initial Unstable burst fracture of third thoracic vertebra, initial Other fracture of third thoracic vertebra, initial encounter for Unspecified fracture of third thoracic vertebra, initial Wedge compression fracture of fourth thoracic vertebra, initial Stable burst fracture of fourth thoracic vertebra, initial Unstable burst fracture of fourth thoracic vertebra, initial Other fracture of fourth thoracic vertebra, initial encounter for Unspecified fracture of fourth thoracic vertebra, initial Wedge compression fracture of T5-T6 vertebra, initial Stable burst fracture of T5-T6 vertebra, initial encounter for Unstable burst fracture of T5-T6 vertebra, initial encounter for Other fracture of T5-T6 vertebra, initial encounter for closed fracture Unspecified fracture of T5-T6 vertebra, initial encounter for 17

18 ICD-10 Code: Facet S22.060A S22.061A S22.062A S22.068A S22.069A S22.070A S22.071A S22.072A S22.078A S22.079A S22.080A S22.081A S22.082A S22.088A S22.089A S32.000A S32.001A S32.002A S32.008A S32.009A S32.010A S32.011A S32.012A S32.018A S32.019A S32.020A S32.021A Wedge compression fracture of T7-T8 vertebra, initial Stable burst fracture of T7-T8 vertebra, initial encounter for Unstable burst fracture of T7-T8 vertebra, initial encounter for Other fracture of T7-T8 thoracic vertebra, initial encounter for Unspecified fracture of T7-T8 vertebra, initial encounter for Wedge compression fracture of T9-T10 vertebra, initial Stable burst fracture of T9-T10 vertebra, initial encounter for Unstable burst fracture of T9-T10 vertebra, initial encounter for Other fracture of T9-T10 vertebra, initial encounter for closed fracture Unspecified fracture of T9-T10 vertebra, initial encounter for Wedge compression fracture of T11-T12 vertebra, initial Stable burst fracture of T11-T12 vertebra, initial encounter for Unstable burst fracture of T11-T12 vertebra, initial encounter for Other fracture of T11-T12 vertebra, initial encounter for Unspecified fracture of T11-T12 vertebra, initial encounter for Wedge compression fracture of unspecified lumbar vertebra, initial Stable burst fracture of unspecified lumbar vertebra, initial Unstable burst fracture of unspecified lumbar vertebra, initial Other fracture of unspecified lumbar vertebra, initial Unspecified fracture of unspecified lumbar vertebra, initial Wedge compression fracture of first lumbar vertebra, initial Stable burst fracture of first lumbar vertebra, initial encounter for Unstable burst fracture of first lumbar vertebra, initial Other fracture of first lumbar vertebra, initial encounter for Unspecified fracture of first lumbar vertebra, initial encounter for Wedge compression fracture of second lumbar vertebra, initial Stable burst fracture of second lumbar vertebra, initial 18

19 ICD-10 Code: Facet S32.022A S32.028A S32.029A S32.030A S32.031A S32.032A S32.038A S32.039A S32.040A S32.041A S32.042A S32.048A S32.049A S32.050A S32.051A S32.052A S32.058A S32.059A S32.10XA S32.110A S32.111A S32.112A S32.119A S32.120A S32.121A S32.122A S32.129A Unstable burst fracture of second lumbar vertebra, initial Other fracture of second lumbar vertebra, initial encounter for Unspecified fracture of second lumbar vertebra, initial Wedge compression fracture of third lumbar vertebra, initial Stable burst fracture of third lumbar vertebra, initial encounter for Unstable burst fracture of third lumbar vertebra, initial Other fracture of third lumbar vertebra, initial encounter for Unspecified fracture of third lumbar vertebra, initial encounter for Wedge compression fracture of fourth lumbar vertebra, initial Stable burst fracture of fourth lumbar vertebra, initial Unstable burst fracture of fourth lumbar vertebra, initial Other fracture of fourth lumbar vertebra, initial encounter for Unspecified fracture of fourth lumbar vertebra, initial Wedge compression fracture of fifth lumbar vertebra, initial Stable burst fracture of fifth lumbar vertebra, initial encounter for Unstable burst fracture of fifth lumbar vertebra, initial Other fracture of fifth lumbar vertebra, initial encounter for Unspecified fracture of fifth lumbar vertebra, initial encounter for Unspecified fracture of sacrum, initial encounter for closed fracture Nondisplaced Zone I fracture of sacrum, initial encounter for Minimally displaced Zone I fracture of sacrum, initial Severely displaced Zone I fracture of sacrum, initial Unspecified Zone I fracture of sacrum, initial encounter for Nondisplaced Zone II fracture of sacrum, initial encounter for Minimally displaced Zone II fracture of sacrum, initial Severely displaced Zone II fracture of sacrum, initial Unspecified Zone II fracture of sacrum, initial encounter for 19

20 ICD-10 Code: Facet S32.130A S32.131A S32.132A S32.139A S32.14XA S32.15XA S32.16XA S32.17XA S32.19XA S32.2XXA Nondisplaced Zone III fracture of sacrum, initial encounter for Minimally displaced Zone III fracture of sacrum, initial Severely displaced Zone III fracture of sacrum, initial Unspecified Zone III fracture of sacrum, initial encounter for Type 1 fracture of sacrum, initial Type 2 fracture of sacrum, initial Type 3 fracture of sacrum, initial Type 4 fracture of sacrum, initial Other fracture of sacrum, initial Fracture of coccyx, initial DESCRIPTION OF SERVICES Pain in the lower back or low back pain is a common concern, affecting up to 90% of Americans at some point in their lifetime. The vast majority of episodes are mild and self-limited. Up to 50% of affected persons will have more than one episode. Low back pain is not a specific disease; rather it is a symptom that may occur from a variety of different processes. Management of back pain that is persistent and disabling despite the use of recommended conservative treatment is challenging. Epidural steroid injections, and facet joint injections and blocks have been employed in the treatment of back pain as an alternative to more invasive interventions. (Chou et al., 2009) Spinal stenosis is described by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) as follows: Spinal stenosis is a narrowing of spaces in the spine (backbone) that results in pressure on the spinal cord and/or nerve roots. This disorder usually involves the narrowing of one or more of three areas of the spine: (1) the canal in the center of the column of bones (vertebral or spinal column) through which the spinal cord and nerve roots run, (2) the canals at the base or roots of nerves branching out from the spinal cord, or (3) the openings between vertebrae (bones of the spine) through which nerves leave the spine and go to other parts of the body. The narrowing may involve a small or large area of the spine. Pressure on the lower part of the spinal cord or on nerve roots branching out from that area may give rise to pain or numbness in the legs. Pressure on the upper part of the spinal cord (that is, the neck area) may produce similar symptoms in the shoulders, or even the legs There are 3 types of spinal stenosis: lateral stenosis, central stenosis, and foraminal stenosis. Lateral stenosis is the most common and is characterized by compression of the nerves and nerve roots as they exit the spinal cord on the way to the extremities. It can be caused by a bulging or herniated disc or bony protrusion that extends beyond the opening in the canal through which the nerve is traveling. Central stenosis occurs when the central canal in the spinal column is narrowed or choked by enlarged bone spurs from arthritis or trauma or degenerative disc disease. Central stenosis of the lumbar spine may lead to pressure on the cauda equina nerve roots (the bundle of roots that branch off at the bottom of the spinal cord), leading to lower extremity pain, numbness or weakness or loss of bowel and/or bladder control. Foraminal stenosis is a condition caused by excessive pressure on, or trapping, of a nerve root by a bone spur in the foramen, or the opening where the nerve root leaves the spinal canal. (Hayes 2015). Facet blocks can be considered a diagnostic or therapeutic procedure. Facet blocks using shortacting local anesthetics can be used to diagnose facet (zygapophyseal) joint syndrome as the cause of chronic back pain. Facet blocks utilizing long acting local anesthetics, anti-inflammatory agents such as corticosteroids, or nerve ablating techniques such as radiofrequency lesioning have been investigated for treatment of chronic back pain attributed to facet joint syndrome. (Hayes, 2007) 20

21 Epidural steroid injection (ESI) is a nonsurgical treatment for managing low back pain and sciatica caused by disc herniation or degenerative changes in the vertebrae. An epidural steroid injection is an injection of long lasting steroid in the epidural space; that is the area which surrounds the spinal cord and the nerves coming out of it. The goal of ESI is to relieve pain, improve function, and reduce the need for surgical intervention. (Hayes 2007, Updated 2014) Chronic nonmalignant back pain is defined as pain lasting 3-6 months or more that is not due to cancer. CLINICAL EVIDENCE Ultrasound Guidance Galiano et al. (2007) compared ultrasound guided facet joint injections with CT-controlled interventions in a prospective randomized clinical trial. Forty adult patients with chronic low back pain were evenly assigned either to an ultrasound or CT- group. The primary outcomes were accuracy and time to final needle placement. Of the patients randomized to ultrasound, 18 were judged to be feasible for an ultrasound approach. In 16 of these patients, the facet joints were clearly visible. In the 2 patients not judged to be feasible for the ultrasound approach, CT placement was performed due to inability to visualize the facet joint. For the ultrasound group, the space to be injected was identified within 5mm of the joint space. All of the needle placements were confirmed by CT. The duration of procedure and radiation dose was 14.3 ± 6.6 minutes and 14.2 ± 11.7 mgy.cm in the ultrasound group, and 22.3 ± 6.3 minutes and ± mgy.cm in the CT group. Both groups showed an effect from facet joint injections, demonstrating accurate needle placement. No difference between groups was detected. The authors concluded that the ultrasound approach to the facet joints is feasible and has minimal risk in the large majority of patients and results in a significant time and radiation dose reduction. The study is limited by small sample size. In addition, if the depth of the facet joint is greater the 8cm, visualization is not feasible with ultrasound. CT guidance is reliable and straightforward in 100% of patients regardless of their physical constitution. The fact that CT requires multiple imaging slices accounts for the increase in radiation exposure. Another study by Galiano et al. (2005) was limited to cadaver studies. The clinical evidence was reviewed on January 14, 2014 with no additional information identified that would change the unproven and not medically necessary conclusions. Facet Injections A facet block is an injection of local anesthetic and/or steroids into or near the facet joint of the spine. Use of diagnostic blocks with injection of local anesthesia into the facet joints or around the medial branch nerves to identify the possible sources of spinal pain appears to be an established diagnostic procedure. However, there is no gold standard for the diagnosis of facet syndrome against which the accuracy of diagnostic facet blocks can be assessed. Single blocks have been compared to what are regarded as diagnostically more valid double blocks using local anesthetic agents with different pharmacologic properties and durations of action. With double blocks, a short- and a long-acting anesthetic are used, preferably administered in a double-blind, random order on separate occasions. In a positive response, pain relief occurs with both but lasts longer with the long-acting anesthetic. Compared to a single-blind, double block, Schwarzer et al. (1994) found that a single lumbar facet joint diagnostic block had a 38% false-positive rate. A systematic review by Boswell et al. (2007) evaluated the effectiveness of 3 types of facet joint interventions (intra-articular injections, medial branch nerve blocks, and neurotomy) in managing chronic spinal pain. The primary outcome measure was pain relief. For intra-articular facet joint injections and medial branch blocks, short-term pain relief was defined as relief lasting less than 6 weeks and long-term relief as 6 weeks or longer. For medial branch blocks, repeated injections at defined intervals provided long-term pain relief. For medial branch radiofrequency neurotomy, short-term pain relief was defined as relief lasting less than 3 months and long-term relief as lasting 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. The authors concluded that for intra- 21