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Coverage criteria policies

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. Providers in all locations except for the counties in Wisconsin listed below must comply with decision support requirements when ordering epidural steroid injections. Approved decision support solutions will utilize criteria to determine the appropriateness of any epidural steroid injection ordered for HealthPartners members. Please see related content at right for a link to the Epidural Steroid Injection Decision Support on the HealthPartners Provider portal.

Providers in these Wisconsin counties are exempt from decision support: Brown, Calumet, Door, Fond Du Lac, Florence, Green Lake, Kewaunee, Manitowoc, Marinette, Marquette, Menominee, Oconto, Outagamie, and Shawano. Epidural steroid injections in those counties are covered without prior authorization or decision support according to member benefits.

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 patient 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 6 weeks; and
  4. The patient has failed conservative therapy (structured exercise, physical therapy, activity modification, pharmacological management);
    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.
    -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 injection:
  1. Requires documentation of 50% pain and/or symptom relief as demonstrated on a Visual Analog Scale at 4 weeks post-primary ESI. A pre and post Visual Analog Scale must be submitted.
  2. Require a minimum of 6 weeks between injections;
  3. Are limited to a total of 4 injections per 12 consecutive months.
  4. Requires documentation of member having tried and failed physical therapy during this episode.

Indications that are not covered

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

  1. Non-radicular back pain
  2. Without guidance by real-time fluoroscopic imaging

Definitions

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

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

Episode is defined as a 6 month consecutive time period corresponding with the member’s pain.

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.

Code

Description

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)

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)

64483

Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level

64484

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

M47.20

Other spondylosis with radiculopathy, site unspecified

M47.819

Spondylosis without myelopathy or radiculopathy, site unspecified

M47.899

Other spondylosis, site unspecified

M47.9

Spondylosis, unspecified

M48.00

Spinal stenosis, site unspecified

M48.05

Spinal stenosis, thoracolumbar region

M48.06

Spinal stenosis, lumbar region

M48.07

Spinal stenosis, lumbosacral region

M48.08

Spinal stenosis, sacral and sacrococcygeal region

M48.50XA-M48.58XS

Collapsed vertebra, not elsewhere classified

M51.15 – M51.17

Intervertebral disc disorders with radiculopathy, thoracolumbar, lumbar & lumbosacral regions

M51.26, M51.27

Other intervertebral disc displacement, lumbar & lumbosacral regions

M51.36, M51.37

Other intervertebral disc degeneration, lumbar & lumbosacral regions

M54.15-M54.17

Radiculopathy, thoracolumbar, lumbar & lumbosacral regions

M54.30-M54.32

Sciatica

M54.40-M54.42

Lumbago with sciatica

M54.5

Lumbago

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M80.08XA-M80.08XS

Age-related osteoporosis with current pathological fracture, vertebra(e)

M80.88XA-M80.88XS

Other osteoporosis with current pathological fracture, vertebra(e)

M84.48XA-M84.48XS

Pathological fracture, other site

M84.58XA-M84.58XS

Pathological fracture in neoplastic disease, other specified site

M84.68XA-M84.68XS

Pathological fracture in other disease, other site

M99.21-M99.23

Subluxation stenosis of neural canal of cervical, thoracic & lumbar regions

M99.31-M99.33

Osseous stenosis of neural canal of cervical, thoracic & lumbar regions

M99.41-M99.43

Connective tissue stenosis of neural canal of cervical, thoracic & lumbar regions

M99.51-M99.53

Intervertebral disc stenosis of neural canal of cervical, thoracic & lumbar regions

M99.61-M99.63

Osseous and subluxation stenosis of intervertebral foramina of cervical, thoracic & lumbar regions

M99.71-M99.73

Connective tissue and disc stenosis of intervertebral foramina of cervical, thoracic & lumbar regions

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.

Bibliography

  1. Chou, R. Subacute and chronic low back pain: Nonsurgical interventional treatment. In: UpToDate, Atlas, SJ (Ed), UpToDate, Waltham, MA. (Accessed on February, 13, 2017.)
  2. Cohen, S. P. (2012). Epidural Steroids, Etanercept, or Saline in Subacute Sciatica. A multicenter, Randomized Trial, Annals of Internal Medicine, Volume 156(8), 551.
  3. ECRI Institute (2012),.ESI Lumbar Radicular Pain. Plymouth Meeting, PA: ECRI Institute.
  4. Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
  5. 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.
  6. Washington Health Technology Assessment: Spinal Injections Final Report (12-14-2010). Accessed April 2013.

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Policy activity

  • 05/18/2005 - Date of origin
  • 12/01/2017 - Effective date
Review date
  • 03/2017
Revision date
  • 11/30/2017

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