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Coverage criteria policies

Discography/Intradiscal Steroid Injections

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

Discography/intradiscal steroid injections require prior authorization.

Coverage

Lumbar provocative discography is covered for the evaluation of discogenic back pain when all of the following criteria are met:

  1. It is ordered by the spine surgeon to determine whether the patient is a surgical candidate or in the anticipation and planning of surgical intervention
  2. There is a failure of prior conservative medical management (structured exercise, physical therapy, activity modification, pharmacological management) - these must be documented on the request for prior authorization;
    Conservative therapy must include physical therapy (PT)
    and may include activity modification, weight loss, and drug therapy. Documentation must correspond to the current episode of pain (within 6 months).
    Formal physical therapy
    , at least four visits over a six week course, including active muscle conditioning is REQUIRED, OR there must be an explicit statement in the clinical documents that explains why such physical therapy is contraindicated. The requirement for physical therapy will not be met if there is a failure to complete prescribed physical therapy for non-clinical reasons. Documentation of formal physical therapy would be the therapist’s notes. If a patient is unable to complete physical therapy (PT) due to progressively, worsening pain and disability, the case will be reviewed on an individual basis by an internal physician reviewer. Documentation in the physical therapist’s notes demonstrating this must be submitted.
  3. When complex imaging studies (e.g., CT, MRI) are inconclusive

Indications that are not covered

Cervical and thoracic discography is considered experimental and investigational and is not covered because there is insufficient evidence to establish the safety and of efficacy of this treatment or its effect on health care outcomes.Functional anesthetic discography (FAD) (involving injection of anesthestic (e.g., lidocaine or bupivacaine) directly into the disc) is considered experimental and investigational because there is insufficient evidence to establish the safety and of efficacy of this treatment or its effect on health care outcomes.

Intradiscal steroid injections are considered experimental/investigational and not covered because there is insufficient evidence to establish the safety and of efficacy of this treatment or its effect on health care outcomes.

Definitions

Discography - an invasive diagnostic tool and is typically performed in conjunction with CT or MRI to localize disc herniation or fissure in the annulus fibrosis. A volume of contrast media is injected into the disc space to determine the integrity of the intervertebral disc. In the normal disc, the annulus fibrosis solidly encloses the nucleus pulposus and is only capable of accepting 1 to 1.5 ml of contrast media. If 2 ml or more of contrast media can be injected, there is likely a degenerative change in the disc. In addition to determining the available volume of the disc, discography is used to reproduce the symptoms associated with a possible herniated disc. The patient's response to pain can help confirm the source of the symptoms. When saline or dye is injected, it pressurizes the disc, and the patient is able to confirm that this pain is the same as the pain he or she has been having.

Functional anesthetic discography (FAD) is a diagnostic procedure that involves the injection of a local anesthetic (e.g., lidocaine or bupivacaine) directly into one or more suspected discs using a balloon-anchored catheter for confirming the presence of injured discs as the source of a member's LBP.  In particular, FAD entails a functional examination; it relies on the member's induction of pain during active patient movement, which is different than the traditional discography.  When the member performs the movement or position that causes pain, a local anesthetic is then injected into the disc in hopes of alleviating the pain.  If the injection relieves the pain, the disc can be further evaluated for potential treatment.  If the injection fails to relieve the pain, the physician can investigate other possible causes of pain.

Intradiscal steroid injection is sometimes performed at the same time as a discography is performed. This procedure lacks scientific evidence that proves its effectiveness.

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

Codes

Description

22899

Unlisted procedure, spine

0213T – 0218T

Injection(s), diagnostic or therapeutic agent, paravetebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, various levels, etc.

72285

Discography, cervical or thoracic, radiological supervision and interpretation

72295

Discography, lumbar, radiological supervision and interpretation

62290

Injection procedure for discography, each level; lumbar

62291

Injection procedure for discography, each level; cervical or thoracic

62292

Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar

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.

References

  1. Alamin, T. F., Kim, M. J., & Agarwal, V. (2011). Provocative lumbar discography versus functional anesthetic discography: a comparison of the results of two different diagnostic techniques in 52 patients with chronic low back pain. The Spine Journal11(8), 756-765.
  2. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 112(4):810-833.
  3. Chou, R.,; Loeser, J., Owens, D., et al.(2009). Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society. Spine.Volume 34 - Issue 10 - pp 1066-1077
  4. Chou, R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas, S. (Ed), UpToDate, Waltham, MA. (Accessed on June 26, 2017.)
  5. Chou, R. Subacute and chronic low back pain: Surgical interventional treatment. In: UpToDate, Atlas, S. (Ed), UpToDate, Waltham, MA. (Accessed on June 26, 2017.)
  6. ECRI Institute. (2007). Spinal fusion and discography for chronic low back pain and uncomplicated lumbar degenerative disc disease..Plymouth Meeting, PA: ECRI Institute.
  7. Hayes Inc. Hayes Medical Technology Directory Report. . Discography for Diagnosis of Low Back Pain. Lansdale, PA. Hayes, Inc. April, 2010; Reviewed March 2014, Archived May, 2015.
  8. Manchikanti, L.,, Abdi, S.,, Atluri S., et al (2013). An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician. . Apr;16(2 Suppl):S49-283. PubMed PMID: 23615883
  9. Onyewu O, Manchikanti L, Falco FJ, et al. (2012). An update of the appraisal of the accuracy and utility of cervical discography in chronic neck pain. Pain Physician; 15(6):E777-E806.
  10. Singh,V., Manchikanti, L., Onyewu, O.,Benyamin, R., Datta, S., Geffert, S., Parr, A., and Falco, F. (2012). An Update of the Appraisal of the Accuracy of Thoracic Discography as a Diagnostic Test for Chronic Spinal Pain. Pain Physician; 15:E757-E776
  11. Singh, V., Manchikanti, L., Shah, V., Dunbar, E. and Glaser, S. (2008). Systematic Review of Thoracic Discography as a Diagnostic Test for Chronic Spinal Pain. Pain Physician. 11:631-642

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Policy activity

  • 08/19/2010 - Date of origin
  • 09/01/2017 - Effective date
Review date
  • 08/2017
Revision date
  • 07/28/2017

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