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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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However, the evidence is of relatively poor quality, and therefore no strong recommendation in Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline support of this therapy was made.

References and Resources Resources Abdi S, Datta S, Lucas LF. Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician. 2005;8(1):127-143.

Abdi S, Datta S, Trescot AM, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician. 2007;10(1):185-212.

Agency for Healthcare Research and Quality (AHRQ) [website]. Treatment of Degenerative Lumbar Spinal Stenosis. Summary, Evidence Report/ Technology Assessment: Number 32. AHRQ

Publication No. 01-E047, March 2001. Available at:

http://www.ahrq.gov/clinic/epcsums/stenosum.htm. Accessed October 23, 2008.

Aldrete JA. Epidural injections of indomethacin for postlaminectomy syndrome: a preliminary report.

Anesth Analg. 2003;96(2):463-468.

American Academy of Neurology (AAN). AAN Summary of Evidence-based Guideline for Clinicians: Use Of Epidural Steroid Injections To Treat Radicular Lumbosacral Pain. AAN, 2007.

American Society of Anesthesiologists (ASA) Task Force on Pain Management, Chronic Pain Section. Practice guidelines for chronic pain management. Anesthesiology. 1997;86:995-1004.

Armon C, Argoff CE, Samuels J, Backonja MM. Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68(10):723-729.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline Number 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0642. December 1994.

Boswell MV, Shah RV, Everett CR, Sehgal N, Mckenzie-Brown AM, Abdi S, Bowman RC, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS,

Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain:

evidence-based practice guidelines. Pain Phys 2005;8(1):1-47.

Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, et al. Interventional techniques:

evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111.

Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am. 2004;86-A(4):670-679.

Carette, S., Marcoux, S., and Truchon, R., et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991;325:1002-1007.

Cyteval C, Fescquet N, Thomas E, et al. Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy. AJNR Am J Neuroradiol. 2006;27(5):978-982.

Derby R, Lee S-H, Kim B-J, et al. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician. 2004;7(4):445-449.

Dreyer SJ, Dreyfuss P, Cole AJ, Windsor RE. Injection procedures. In: Cole AJ, Herring SA, eds. The

Low Back Pain Handbook: A Practical Guide for the Primary Care Clinician. Philadelphia, PA:

Hanley & Belfus Inc.; 1997:227-243.

ECRI. Custom Hotline Response. Facet Joint Injection Therapies for Chronic, Back Pain. March 2008a.

ECRI. Custom Hotline Response. Epidural Steroid Injections for Spinal Stenosis. March 2007.

ECRI. Custom Hotline Response. Epidural Injection Therapy for Chronic Back Pain. March 2008b.

Everett CR, Baskin MN, Novoseletsky D, et al. Flushing as a side effect following lumbar transforaminal epidural steroid injection. Pain Physician. 2004;7(4):427-429.

Hayes, Inc. Medical Technology Directory. Facet Blocks for Chronic Back Pain. Lansdale, PA:

Hayes, Inc.; October 2006. Last update October 14, 2007.

Hayes, Inc. Medical Technology Directory. Epidural Steroid Injections for Low Back Pain and Sciatica. Lansdale, PA: Hayes, Inc.; October 2007.

Jackson RP. The facet syndrome: myth or reality? Clin Orthop Rel Res. 1992;279:110-121.

Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine. 2001;26(9):1059-1067.

Khot A, Bowditch M, Powell J, Sharp D. The use of intradiscal steroid therapy for lumbar spinal discogenic pain: a randomized controlled trial. Spine. 2004;29(8):833-836.

Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ et al. Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. March 6, 2007.

Lilius, G., Laasonen, E., and Myullynen, P., et al. Lumbar facet joint syndrome: a randomized clinical trial. J Bone Joint Surg Br. 1989;71-B:668-684.

Manchikanti L, Manchikanti KN, Damron KS, Pampati V. Effectiveness of cervical medial branch blocks in chronic neck pain: A prospective outcome study. Pain Physician 2004; 7:195-202.





Manchikanti L, Manchikanti KN, Manchukonda R, Pampati V, Cash KA. Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. Pain Physician. 2006 Apr;9(2):97-105.

Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD.

Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain:

preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician. 2007 May;10(3):425-40.

Mayer, T. G., Gatchel, R. J., Keeley, J., McGeary, D., Dersh, J., and Anagnostis, C. A randomized clinical trial of treatment for lumbar segmental rigidity. Spine. 2004;29(20):2199-205.

McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005;5(2):191-201.

National Heart, Lung and Blood Institute (NHLBI), Obesity Education Initiative, Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Rockville (MD): U.S.

Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute; 1998.

Nelemans PJ, deBie RA, deVet HC, Sturmans F. Injection therapy for subacute and chronic low back pain. Spine. 2001;26(5):501-15.

North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care.

Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. 2007. Available at:

http://www.spine.org/Documents/NASSCG_Stenosis.pdf. Accessed October 23, 2008.

Price C, Arden N, Coglan L, Rogers P. Cost-effectiveness and safety of epidural steroids in the management of sciatica. Health Technol Assess. 2005;9(33):1-58.

Resnick, D. K., Choudhri, T. F., Dailey, A. T., Groff, M. W., Khoo, L., Matz, P. G., Mummaneni, P., Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline Watters, W. C. 3rd, Wang, J., Walters, B. C., and Hadley, M. N. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2005;2(6):707-15.

Revel, M., Poiraudeau, S., Auleley, G. R., Payan, C., Denke, A., Nguyen, M., Chevrot, A., and Fermanian, J. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints [see comments]. Spine.

1998;23(18):1972-6.

Schwarzer, A., Aprill, C., and Derby, R., et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine. 1994;19:1132Shih, C., Lin, G. Y., Yueh, K. C., and Lin, J. J. Lumbar zygapophyseal joint injections in patients with chronic lower back pain. J Chin Med Assoc. 2005;68(2):59-64.

Valat JP, Giraudeau B, Rozenberg S, et al. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003;62(7):639-643.

Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br. 2005;87(3):352-355.

–  –  –

Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service 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 benefit document.

CPT Codes (Facet Injection):

64470 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve;

cervical or thoracic, single level 64472 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve;

cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64475 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve;

lumbar or sacral, single level 64476 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve;

lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

CPT Codes (Epidural Injection):

62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal) 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)

Diagnosis Codes (Facet Injection):

720.1 Spinal enthesopathy 721.0 Cervical spondylosis without myelopathy 721.3 Lumbosacral spondylosis without myelopathy 722.10 Displacement of lumbar intervertebral disc without myelopathy 722.4 Degeneration of cervical intervertebral disc 722.52 Degeneration of lumbar or lumbosacral intervertebral disc 722.71 Intervertebral cervical disc disorder with myelopathy, cervical region 722.73 Intervertebral lumbar disc disorder with myelopathy, lumbar region 722.81 Postlaminectomy syndrome, cervical region 722.83 Postlaminectomy syndrome, lumbar region 722.91 Other and unspecified disc disorder of cervical region 722.93 Other and unspecified disc disorder of lumbar region 723.1 Cervicalgia 724.02 Spinal stenosis of lumbar region 724.2 Lumbago 724.3 Sciatica

Diagnosis Codes (Epidural Injection):

355.0 Lesion of sciatic nerve 721.3 Lumbosacral spondylosis without myelopathy 721.42 Spondylosis with myelopathy, lumbar region 722.10 Displacement of lumbar intervertebral disc without myelopathy Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline 722.52 Degeneration of lumbar or lumbosacral intervertebral disc 722.73 Intervertebral lumbar disc disorder with myelopathy, lumbar region 722.83 Postlaminectomy syndrome, lumbar region 722.93 Other and unspecified disc disorder of lumbar region 724.02 Spinal stenosis of lumbar region 724.2 Lumbago 724.3 Sciatica 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 724.6 Disorders of sacrum 956.0 Injury to sciatic nerve

ICD-9 Procedure Codes:

03.91 Injection of anesthetic into spinal canal for analgesia 03.92 Injection of other agent into spinal canal 04.81 Injection of anesthetic into peripheral nerve for analgesia This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.

Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Epidural Steroid and Facet Injections for Spinal Pain- Commercial Medical Management Guideline TITLE: Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography Authorized By: Medical Management Guideline Committee

Adoption Date: 09/16/09 Revision Date:

Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.



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