Humana Injections for Chronic Pain Conditions Form

Description

Injections for chronic pain conditions may be given for either diagnostic or therapeutic (treatment) purposes and may include epidural steroid injections, facet joint injections, regional sympathetic nerve blocks, sacroiliac joint injections, trigger point injections, dry needling of trigger points and/or peripheral nerve blocks. These injections are often included as part of a pain management program.

Epidural Steroid Injections

An epidural steroid injection (ESI) is used to help reduce radicular spinal pain that may be caused by pressure on a spinal nerve root as a result of a herniated disc, degenerative disc disease or spinal stenosis. This treatment is most frequently used for low back pain, though it may also be used for cervical (neck) or thoracic (midback) pain. An anesthetic medication, with or without a steroid (eg, corticosteroid, dexamethasone), is injected into the epidural space near the affected spinal nerve root with the assistance of computed tomography (CT) or fluoroscopy which allows the physician to view the placement of the needle. The goal of this treatment is to reduce inflammation and block the spinal nerve roots to relieve radicular pain or sciatica. It can also provide sufficient pain relief to allow the individual to progress with their rehabilitation program.

Approaches to the epidural space for the injection include:

• Caudal – The needle is placed near the coccyx (tailbone) into the sacral hiatus, allowing the treatment of pain which radiates into the lower extremities. This approach is commonly used to treat lumbar radiculopathy after prior surgery in the low back (post-laminectomy pain syndrome).
• Interlaminar – The needle is placed between the lamina of two vertebrae directly from the middle of the back. Medication is delivered to the nerve roots, via the epidural space, on both the right and left sides of the inflamed area at the same time.
• Selective nerve root block (SNRB) – The needle targets a specific nerve root, rather than the epidural space, delivering an anesthetic along the nerve itself. These injections generally should only be used for diagnostic purposes, often as part of surgical planning. While SNRBs are technically not an ESI, they are frequently discussed with them, and the terms may also erroneously be used interchangeably. They may also be referred to as diagnostic selective nerve root blocks (DSNRBs).
• Transforaminal – The needle is placed under radiographic guidance in such a way as to allow the medication to be directly applied onto the affected spinal nerve via the intervertebral foramen that lodges the nerve. This method treats one side at a time but, depending on the volume of the medication used, it may spread to one or multiple levels; it has been proposed to inject one or multiple levels during the same session, and either one or both sides. (Refer to Coverage Limitations section, regarding multiple level injections)

Facet Joint Injections

Facet Joint Injections

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Facet injections, also known as facet blocks or medial branch blocks, are injections of a local anesthetic, with or without a steroid medication, into the facet joints or their nerve supply, the medial branch nerve.

Facet injections may be given for diagnostic purposes to determine if the facet joint is the source of pain16 and must be performed under CT- or fluoroscopy-guidance. If the pain is relieved, the physician will know that the facet joint is likely to be the source of pain.

Facet denervation may follow a successful diagnostic facet block. For information regarding facet denervation, please refer to Neuroablative Techniques for Chronic Pain Medical Coverage Policy.

Regional Sympathetic Nerve Blocks

Regional sympathetic nerve blocks are performed by injecting a local anesthetic into the region of the relevant sympathetic ganglia, for the treatment of complex regional pain syndrome ([CRPS], previously known as reflex sympathetic dystrophy [RSD]). At the cervical level, these blocks may be referred to as stellate ganglion blocks and in the thoracic or lumbar level as paravertebral sympathetic blocks. As with other blocks, these may both aid in diagnosis of CRPS and be given as a therapeutic injection.

Sacroiliac Joint Injections

Sacroiliac (SI) joint injections are performed by injecting a local anesthetic, with or without a steroid medication, into the SI joints. These injections may be given for diagnostic purposes to determine if the SI joint is the source of the low back pain or may be performed to treat SI joint pain that has previously been diagnosed. If the pain is relieved, the physician will know that the SI joint appears to be the source of pain. This may be followed up with therapeutic injections of anti-inflammatory (steroid) and/or local anesthetic medications to relieve pain for longer periods.

Trigger Point Injections

Trigger point injections (TPI) are injections of a local anesthetic, with or without a steroid medication, into a painful area of a muscle that contains the trigger point. The purpose of a TPI is to relax the area of intense muscle spasm, effectively inactivate the trigger point and provide prompt symptomatic pain relief.

Dry Needling of Trigger Points

Dry needling differs from traditional acupuncture, even though it does make use of acupuncture-type needles. Acupuncture follows the principles of energy flow as a guide to where the needles will be inserted; in dry needling, needles are inserted directly into a myofascial trigger point, in an attempt to inactivate it, thereby theoretically decreasing the associated pain. Dry needling, even though it targets a trigger point, does differ from a trigger point injection, as there is no injection of medication or fluid. (Refer to Coverage Limitations section)

Peripheral Nerve Block

Peripheral nerve blocks consist of injection of a local anesthetic, with or without a steroid, into a peripheral nerve or a nerve ganglion, in an attempt to block pain signals and in theory provide prolonged relief from pain. Examples of peripheral nerve blocks include, but may not be limited to, cluneal nerve block, coccygeal nerve block, ganglion impar block, genicular nerve block, obturator nerve block or splanchnic nerve block. (Refer to Coverage Limitations section)

Other Therapeutic Injections

Injections may also be given into other structures in an attempt to alleviate chronic pain.

Examples include, but may not be limited to, iliotibial (IT) band injection, intradiscal injection, pedicle screw block/hardware block of instrumentation used in spinal fusion or sacrococcygeal junction/sacrococcygeal ligament injection. (Refer to Coverage Limitations section)

For information regarding combined therapy (also known as combination electrochemical therapy, combination electrochemical treatment or CET), please refer to Electrical Stimulators for Pain and Nausea/Vomiting Medical Coverage Policy.

For information regarding occipital nerve blocks, please refer to Headache and Occipital Neuralgia Treatments Medical Coverage Policy.

Coverage Determination

NOTE: The scope of this policy is limited to CHRONIC pain management; it is NOT intended for use in consideration of acute postoperative pain control.

Epidural Steroid Injections

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for epidural steroid injections via caudal, interlaminar or transforaminal/SNRB approach for back and neck pain when ALL of the following criteria are met:

• Failure to improve after 4 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months, including ALL of the following:
  1. Activity/lifestyle modification; AND
  2. Medications (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], non-narcotic analgesics) if medically appropriate and not contraindicated; AND
  3. Physical therapy (PT), including a home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• Pain is radicular* in nature (radicular signs may include, but are not limited to, a positive straight leg raise or a dermatomal pattern of sensory loss); AND
• ††Maximum number of nerve root levels that may be performed in one session**:
  1. Caudal and interlaminar: injection at only 1 nerve root level per session, AND only 1 anatomical region^ per session AND not in conjunction with a transforaminal injection; OR
  2. Transforaminal/SNRB: no more than 2 injections per session (a single nerve root level bilaterally or 2 nerve root levels unilaterally) AND only one anatomical region^ per session; AND
• Real-time imaging guidance (CT scan or fluoroscopy) must be used to assure proper needle placement (this is considered integral to the primary procedure and not separately reimbursable)

*In low back pain, radicular means pain and/or numbness that radiates below the knee (this may also be referred to as lumbar radiculopathy)16; in neck pain, it is pain,

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Numbness or weakness in the shoulder, arm, wrist or hand (this may also be referred to as cervical radiculopathy).7**A session is defined as any and all epidural steroid injections or spinal procedures/injections performed on a single calendar day.^For the purpose of pain injections, there are 2 anatomical regions of the spine (defined as (1) the cervical and thoracic spine and (2) the lumbar and sacral spine).

Diagnostic Phase:

• During the diagnostic phase, the individual may receive 2 injections at intervals of no sooner than 2 weeks; AND
• If diagnostic phase is completed and unsuccessful^^, no further injections are considered medically necessary^^A successful diagnostic phase is one in which there is at least a 50% reduction in pain and/or symptoms with one of these injections.

Therapeutic Phase:

• If the diagnostic phase is completed, the frequency of injections must be at least 2 months apart during the therapeutic phase, provided the individual has at least a 50% relief in pain and/or symptoms for 2 months; AND
• Total of 4 therapeutic epidural steroid injections per anatomical region^ per rolling 12 month period† may be performed, only upon return of pain and/or deterioration in function AND only when responsiveness to prior injections has occurred (the individual should have at least a 50% reduction in pain and/or symptoms for 2 months)

†A rolling 12 month period is 12 months after an event, regardless of what month the initial event took place (e.g., first diagnostic injection is given August 1, 2023, the rolling 12-month period would end July 31, 2024).

Humana members may be eligible under the Plan for epidural steroid injections (caudal, interlaminar, transforaminal) for pain unresponsive to conservative measures related to the following conditions (a total of 6 injections per rolling 12 month period† may be administered):

• Cancer (tumors or metastasis involving the spine); OR
• Complex regional pain syndrome (CRPS)/reflex sympathetic dystrophy (RSD); OR
• Herpes zoster/postherpetic neuralgia

Coverage Limitations

Epidural Steroid Injections

Humana members may NOT be eligible under the Plan for epidural steroid injections (caudal, interlaminar, transforaminal/SNRB) for any indications other than those listed above including, but may not be limited to:

• A preconceived treatment plan (e.g., a series of 3 injections regardless of response to the prior injection); OR
• Epidural steroid injections performed at multiple nerve root levels (in excess of the maximum number†† outlined in the Coverage Determination section) OR at multiple anatomical regions^ during the same session (same date of service); OR
• Epidural steroid injections (regardless of the approach used) performed without imaging guidance; OR
• Epidural steroid injections via placement of an indwelling catheter for administration of a continuous infusion or intermittent bolus; OR
• Lumbar spinal stenosis in the absence of radiculopathy*; OR
• Nonradicular pain (unless related to cancer, CRPS/RSD or herpes zoster/postherpetic neuralgia); OR
• Repeat epidural injections when significant improvement has occurred after the initial injection or any subsequent injections.

Repeat injections should only be performed upon return of pain and deterioration in the functional status; OR

• Repeat therapeutic epidural injections in the absence of clinical improvements in pain and function after the initial 2 diagnostic injections; OR

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

When other types of injections are performed on the same date of service, including, but not limited to, facet injections, sacroiliac joint injections, sympathetic blocks§ and/or trigger point injections. (Multiple injections on the same day could lead to an inaccurate or lack of diagnosis)

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the use of ultrasound guidance for needle placement. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for monitored anesthesia care (MAC) for epidural steroid injections. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Standard medical practice consists of local anesthesia and moderate sedation⊕ (99152, 99153).

Humana members may NOT be eligible under the Plan for moderate sedation administered by a provider (that is, a physician or CRNA) OTHER THAN the physician who is performing the diagnostic or therapeutic epidural steroid injection (99156, 99157). This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Note: These statements for moderate sedation, MAC or general anesthesia with pain management injections only apply to ADULTS. Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

§Sympathetic blocks include stellate ganglion blocks in the neck and lumbar sympathetic blocks for lower extremity pain.

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

¶Moderate sedation services are provided by the same physician or other qualified health care professional who is performing the diagnostic or therapeutic procedure that the sedation supports; this requires the presence of an independent trained observer (eg, circulating nurse) to assist in the monitoring of the individual’s level of consciousness and vital signs.

Coverage Facet Joint Injections/Medial Branch Nerve Blocks

Facet Joint Injections/Medial Branch Nerve Blocks

Humana members may be eligible under the Plan for diagnostic facet joint injections or medial branch nerve blocks for back or neck pain when facet joint syndrome is suspected and ALL of the following criteria are met:

Coverage Determination

• Absence of nonfacet pathology per clinical assessment or radiology imaging that could explain the source of the pain (including, but may not be limited to, fracture, infection, significant spinal deformity or tumor); AND
• Absence of radiculopathy*; AND
• Failure to improve after 6 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months, including ALL of the following:
  1. Activity/lifestyle modification; AND
  2. Medications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; AND
  3. PT, including HEP (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• A second confirmatory injection is to be done IF the first injection was successful¶; the second injection should be no sooner than 3 weeks after the first, AND at the same level(s) as the initial injection; AND
• No more than 3 levels of facet joint injections per side, per anatomical region^ may be injected per session; AND
• Pain that is aggravated by extension, rotation or lateral bending of the spine and is not typically associated with neurological deficits; AND
• Real-time imaging guidance (CT scan or fluoroscopy) must be used to assure proper needle placement (this is considered integral to the primary procedure and not separately reimbursable)

¶A successful diagnostic facet joint injection or medial branch block is one that provides at least 80% pain relief (with the duration being consistent with the agent used for the injection).

Coverage Limitations

Facet Joint Injections, Medial Branch Nerve Blocks Humana members may NOT be eligible under the Plan for facet joint injections or medial branch nerve blocks for any indications other than those listed above including, but may not be limited to:

• A preconceived treatment plan (eg, a series of 3 injections regardless of response to the prior injection); OR
• A second confirmatory/diagnostic injection if the first was not successful¶; OR
• Diagnostic facet joint injections/medial branch nerve blocks performed without a plan to perform radiofrequency ablation if the block were to be successful; OR
• Facet joint injections performed without imaging guidance; OR
• Therapeutic facet joint injections/medial branch blocks (for the TREATMENT of back or neck pain); OR
• When other types of injections are performed on the same date of service including, but not limited to, epidural steroid injections, sacroiliac joint injections, sympathetic blocks§ and/or trigger point injections.

(Multiple injections on the same day could lead to an inaccurate or lack of diagnosis)

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the use of ultrasound guidance for needle placement. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for monitored anesthesia care (MAC) for facet joint injections or medial branch nerve blocks. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Standard medical practice consists of local anesthesia and moderate sedation¶ (99152, 99153).

Humana members may NOT be eligible under the Plan for moderate sedation administered by a provider (that is, a physician or CRNA) OTHER THAN the physician who is performing the diagnostic facet joint injection or medial branch nerve blocks (99156, 99157). This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Note: These statements for moderate sedation, MAC or general anesthesia with pain management injections only apply to ADULTS. Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

Coverage Determination

Regional Sympathetic Nerve Blocks

Humana members may be eligible under the Plan for regional sympathetic nerve blocks when the following criteria are met:

• Diagnosis when sympathetically mediated CRPS is suspected as evidenced by ALL of the following criteria being met:

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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Continued, ongoing pain, disproportionate to any inciting event (eg, surgery, trauma); AND

• ONE or more symptoms from EACH of the following categories:

1. Sensory: hyperesthesia, allodynia
2. Vasomotor: temperature asymmetry, skin color changes, skin color asymmetry
3. Sudomotor/edema: edema, sweating changes, sweating asymmetry
4. Motor/trophic: decreased range of motion (ROM), motor dysfunction (weakness, tremor, dystonia), trophic changes (hair, nails, skin); AND

• ONE or more findings on physical exam in TWO or more of the following categories:

1. Sensory: evidence of: hyperalgesia (to pinprick), allodynia (to light touch)
2. Vasomotor: evidence of: temperature asymmetry, skin color changes, skin color asymmetry
3. Sudomotor/edema: evidence of: edema, sweating changes, sweating asymmetry
4. Motor/trophic: evidence of: decreased ROM, motor dysfunction (weakness, tremor, dystonia), trophic changes (hair, nails, skin); AND

Failure to improve after 12 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months, including ALL of the following:

• Activity/lifestyle modification; AND
• Medications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; AND
• PT, including HEP (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• Real-time imaging guidance (CT scan or fluoroscopy) must be used to assure proper needle placement for either diagnostic or therapeutic injections (this is considered integral to the primary procedure and not separately reimbursable); AND
• Utilization of these blocks is to be with the intent to allow participation in an active rehabilitation program

Diagnostic Phase:

• A diagnostic block is performed to confirm (or disprove) the presence of sympathetically mediated CRPS; AND
• A second diagnostic block may be performed if the initial block was successful (a 50% reduction in pain and improved function) and if performed within the first 2 weeks of the initial block; AND
• If the diagnostic phase is completed and unsuccessful (less than 50% pain relief and no improvement in function), no further injections will be covered

Therapeutic Phase:

• If the diagnostic phase is completed and successful (at least a 50% reduction in pain and improvement in function), therapeutic injections may be initiated; AND
• Up to a maximum of 6 total blocks may be performed at a frequency of no more than one per week (per rolling 12 month period‡):

AND all of the following:

• A 50% reduction in pain is achieved; AND
• Decrease in pain medication use; AND

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

• Improved/increased functional ability (increased ROM, strength and use of the extremity in activities of daily living [ADLs], increased tolerance to touch); AND
• Ongoing participation in an active rehabilitation program

Coverage Limitations

Regional Sympathetic Nerve Blocks

Humana members may NOT be eligible under the Plan for regional sympathetic nerve blocks for any indications other than those listed above including, but may not be limited to:

• Diagnostic block was not successful (less than 50% reduction in pain); OR
• Individual is not capable of or willing to participate in an ongoing, active rehabilitation program; OR
• Regional sympathetic nerve blocks performed without imaging guidance; OR
• Repeat therapeutic block when there has not been any decrease in pain medication use, increased function/participation in ADLs or increased tolerance to touch; OR
• When other types of injections are performed on the same date of service including, but not limited to, epidural steroid injections, facet joint blocks/medial branch nerve blocks, sacroiliac joint injections and/or trigger point injections. (Multiple injections on the same day could lead to an inaccurate or lack of diagnosis)

All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the use of ultrasound guidance for needle placement. This is considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 15 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for monitored anesthesia care (MAC) for regional sympathetic nerve blocks. This is considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition. Standard medical practice consists of local anesthesia and moderate sedation◊ (99152, 99153).

Humana members may NOT be eligible under the Plan for moderate sedation administered by a provider (that is, a physician or CRNA) OTHER THAN the physician who is performing the diagnostic or therapeutic regional sympathetic nerve blocks (99156, 99157). This is considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Note: These statements for moderate sedation, MAC or general anesthesia with pain management injections only apply to ADULTS.

Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

Coverage Determination

Sacroiliac Joint Injections

Humana members may be eligible under the Plan for intra-articular sacroiliac joint injections when the following criteria are met:

• Chronic low back pain when the sacroiliac joint is suspected to be the source of pain; AND
• Failure to improve after 12 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months, including ALL of the following:
  • Activity/lifestyle modification; AND
  • Medications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; AND
  • PT, including HEP (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• Positive response (reproduction of individual's typical SIJ pain) to at least 2 of the following provocative tests/maneuvers:
  • Compression test
  • Distraction test
  • FABER test (also referred to as Patrick test)
  • Gaenslen's test
  • Thigh thrust test (also referred to as posterior pelvic pain provocation)
• Sacroiliac joint injections are to be performed with imaging guidance (CT scan or fluoroscopy) to assure correct needle placement (this is considered integral to the primary procedure and not separately reimbursable)

Diagnostic Phase:

• During the diagnostic phase, an individual may receive 2 injections at intervals of no sooner than 2 weeks; AND
• If injections are to be done for different joints (left versus right) they are to be done at intervals of no sooner than one week apart (though it is recommended that both joints be injected at the same time); AND
• If the diagnostic phase is completed and unsuccessful (less than an 80% reduction in pain and/or symptoms), no further injections will be covered

Therapeutic Phase:

• If the diagnostic phase is completed, the frequency of injections must be at least 2 months apart during the therapeutic phase, provided the individual has at least an 80% relief in pain and/or symptoms for 6 weeks; AND
• If injections are to be done for different joints (left versus right), and the above criteria are met, the frequency is to remain at least 2 months between injections (though it is recommended that both sides be treated at the same time, rather than one at a time); AND

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Total of 4 therapeutic injections (per joint per rolling 12 month period‡) may be performed only upon return of pain and/or deterioration in function and only when responsiveness to prior injections has occurred (the individual should have at least an 80% reduction in pain and/or symptoms for 6 weeks)

Coverage Limitations

Sacroiliac Joint Injections

Humana members may NOT be eligible under the Plan for sacroiliac joint injections for any indications other than those listed above including, but not limited to:

• Lateral branch nerve blocks to the SI joint for diagnostic or therapeutic purposes OR for diagnostic purposes prior to a neuroablative procedure to the SI joint. For information regarding coverage determination/limitations, please refer to Neuroablative Techniques for Chronic Pain Medical Coverage Policy; OR
• Repeat SI joint injections in the absence of clinical improvement in pain and function after the initial 2 diagnostic injections; OR
• Repeat SI joint injections when significant improvement has occurred after the initial injection or any subsequent injections. Repeat injections should only be performed upon return of pain and deterioration in the functional status; OR
• SI joint injections performed without imaging guidance; OR
• When other types of injections are performed on the same date of service including, but not limited to, epidural steroid injections, facet injections, sympathetic blocks§ and/or trigger point injections. (Multiple injections on the same day could lead to an inaccurate or lack of diagnosis)

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the use of ultrasound guidance for needle placement. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for monitored anesthesia care (MAC) for sacroiliac joint injections. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Standard medical practice consists of local anesthesia and moderate sedation◊ (99152, 99153).

Humana members may NOT be eligible under the Plan for moderate sedation administered by a provider (that is, a physician or CRNA) OTHER THAN the physician who is performing the diagnostic or therapeutic sacroiliac joint injection (99156, 99157). This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Note: These statements for moderate sedation, MAC or general anesthesia with pain management injections only apply to ADULTS.

Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

Coverage Determination

Trigger Point Injections

Humana members may be eligible under the Plan for trigger point injections for the treatment of myofascial pain syndrome when the following criteria are met:

• Presence of symptomatic palpable trigger point(s); AND
• Failure to improve after 12 consecutive weeks of conservative treatment under the direction of a healthcare professional within the past 12 months, including ALL of the following:
  • Activity/lifestyle modification; AND
  • Medications (eg, NSAIDs, non-narcotic analgesics) if medically appropriate and not contraindicated; AND
  • PT, including HEP (for information regarding coverage determination/ limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND

Diagnostic (Stabilization) Phase:

• During the diagnostic (stabilization) phase, an individual may receive injections at intervals of no sooner than 1 week; AND
• Up to 4 sets of injections may be necessary to diagnose the source of the individual’s pain and achieve a therapeutic effect; AND
• If diagnostic (stabilization) phase is completed and unsuccessful††, no further injections are covered

Therapeutic Phase:

• If the diagnostic (stabilization) phase is completed, the frequency of injections must be at least 2 months apart during the therapeutic phase, provided the individual has at least a 50% relief in pain and/or symptoms for 6 weeks; AND
• Total of 6 sessions of therapeutic trigger point injections per rolling 12 month period† may be performed only upon return of pain and/or deterioration in function AND only when responsiveness to prior injections has occurred (the individual should have at least a 50% reduction in pain and/or symptoms for 6 weeks)

Coverage Limitations

Trigger Point Injections

Humana members may NOT be eligible under the Plan for trigger point injections for any indications other than those listed above including, but not limited to:

• Repeat therapeutic trigger point injections in the absence of clinical improvement in pain and function after the initial diagnostic injections; OR
• Repeat trigger point injections when significant improvement has occurred after the initial injection or any subsequent injections. Repeat injections should only be performed upon return of pain and deterioration in the functional status; OR
• When other types of injections are performed on the same date of service including, but not limited to, epidural steroid injections, facet injections, sacroiliac joint injections and/or sympathetic blocks§. (Multiple injections on the same day could lead to an inaccurate or lack of diagnosis)

All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for dry needling of trigger points (needle insertion without injection). This is considered experimental/ investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the use of ultrasound guidance for needle placement. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for monitored anesthesia care (MAC) for trigger point injections. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition. Standard medical practice consists of local anesthesia and moderate sedation◊ (99152, 99153).

Humana members may NOT be eligible under the Plan for moderate sedation administered by a provider (that is, a physician or CRNA) OTHER THAN the physician who is performing the diagnostic or therapeutic trigger point injection (99156, 99157). This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 21 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Note: These statements for moderate sedation, MAC or general anesthesia with pain management injections only apply to ADULTS. Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

Coverage Other Miscellaneous Injections for Pain Conditions

Coverage Limitations

Other Miscellaneous Injections for Pain Conditions

Humana members may NOT be eligible under the Plan for the following injections for any indication, including for management/treatment of chronic pain:

• Cluneal nerve block; OR
• Coccygeal nerve block; OR
• Ganglion impar block; OR
• Genicular nerve block; OR
• Iliotibial (IT) band injection; OR
• Intradiscal injection with ANY substance (eg, allogenic cellular product, allogenic tissue-based product, mesenchymal stem cells, methylene blue, notochordal cell-derived matrix, oxygen/ozone, platelet rich plasma [PRP], steroids, tumor necrosis factor [TNF] alpha, VIA disc allograft [may also be referred to as VIA disc matrix]); OR
• Obturator nerve block; OR
• Paravertebral block for chronic pain (paravertebral blocks may be appropriate when used for immediate postoperative pain management, for specific surgical procedures, however, this indication is outside of the scope of this Medical Coverage Policy); OR
• Pedicle screw block/hardware block of instrumentation used in spinal fusions; OR
• Repetitive peripheral nerve blocks for chronic nonmalignant pain; OR

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• Sacrococcygeal junction/sacrococcygeal ligament injection (for any indication, including coccydynia); OR
• Splanchnic nerve block

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for moderate sedation, monitored anesthesia care (MAC) or general anesthesia provided for any injections listed in this section (and including, but may not be limited to, peripheral joint injections [eg, hip or knee]) related to pain management procedures. These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Note: This statement for moderate sedation, MAC or general anesthesia with pain management injections only applies to ADULTS. Moderate sedation (99151, 99152, 99153, 99155, 99156, 99157), MAC or general anesthesia with pain management injections may be medically necessary for an individual 17 years of age or younger.

Background

Additional information about back pain, facet joints, myofascial pain syndrome, sacroiliac joints and trigger points may be found from the following websites:

• American Academy of Orthopaedic Surgeons
• American College of Rheumatology
• National Institute of Neurological Disorders and Stroke
• National Library of Medicine

Medical Alternatives

Alternatives to epidural steroid injections, facet injections/medial branch nerve blocks, regional sympathetic nerve blocks and sacroiliac joint injections include, but may not be limited to, the following:

• Orthopedic braces (please refer to Orthotics Medical Coverage Policy)
• Orthopedic/neurological surgery

Alternatives to peripheral nerve blocks include, but may not be limited to, the following:

• Physical therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
• Prescription drug therapy

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

• CPT® Code(s)
• Description
• Comments

• 01991
• Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position
• Not Covered if performed for individuals over 18 years of age

• 01992
• Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position
• Not Covered if performed for individuals over 18 years of age

• 20550
• Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
• Not Covered if used to report any treatment outlined in Coverage Limitations section

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• 20551
• Injection(s); single tendon origin/insertion
• Not Covered if used to report any treatment outlined in Coverage Limitations section

• 20552
• Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

• 20553
• Injection(s); single or multiple trigger point(s), 3 or more muscles

• 20560
• Needle insertion(s) without injection(s); 1 or 2 muscle(s)
• Not Covered

• 20561
• Needle insertion(s) without injection(s); 3 or more muscles
• Not Covered

• 20605
• . wae a ae Arthrocentesis, aspiration and/or injection, intermediate joint . . . : or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
• Not Covered if used to report any treatment . . outlined 'n Coverage Limitations section

• 20999
• Unlisted procedure, musculoskeletal system, general
• Not Covered if used to report any treatment outlined in Coverage Limitations section

• 22899
• Unlisted procedure, spine
• Not Covered if used to report any treatment outlined in Coverage Limitations section

• 27096
• Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

• 62320
• 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, cervical or thoracic; without imaging guidance
• Not Covered

• 62321
• 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, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 25 of 45

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• 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 Not Covered if performed for chronic pain conditions
• 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)
• 64450 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch Not Covered if used to report any treatment outlined in Coverage Limitations section
• 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Not Covered
• 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed Not Covered
• 64461 Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed) Not Covered if used to report any treatment outlined in Coverage Limitations section
• 64462 Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure) Not Covered if used to report any treatment outlined in Coverage Limitations section
• 64463 Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed) Not Covered if used to report any treatment outlined in Coverage Limitations section

• 64479 - Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level
• 64480 - Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
• 64483 - Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
• 64484 - Injection(s), anesthetic agent(s) 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)
• 64490 - 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 - Not Covered if used to report any injection outlined in Coverage Limitations section
• 64491 - 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) - Not Covered if used to report any injection outlined in Coverage Limitations section
• 64492 - 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) - Not Covered if used to report any injection outlined in Coverage Limitations section
• 64493 - 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 - Not Covered if used to report any injection outlined in Coverage Limitations section
• 64494 - 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) - Not Covered if used to report any injection outlined in Coverage Limitations section

Injections for Chronic Pain Conditions Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0486-032 Page: 26 of 45

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• 64495 - (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).

• 64510 - Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
• 64520 - Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
• 64640 - Destruction by neurolytic agent; other peripheral nerve or branch Not Covered if used to report any treatment outlined in Coverage Limitations section
• 64680 - Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus Not Covered if used to report any treatment outlined in Coverage Limitations section
• 64999 - Unlisted procedure, nervous system Not Covered if used to report any treatment outlined in Coverage Limitations section
• 76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Not Covered if used to report any treatment outlined in Coverage Limitations section
• 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)
• 77012 - Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation Not Covered if used to report any treatment outlined in Coverage Limitations section

Injections for Chronic Pain Conditions Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0486-032 Page: 28 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

CPT® Code(s)

• 99151

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

• 99152

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

• 99153

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)

• 99155

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age

• 99156
• Not Covered for individuals over 18 years of age when performed in conjunction with an injection for chronic pain conditions

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older

Injections for Chronic Pain Conditions Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0486-032 Page: 29 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)Not Covered for individuals over 18 years of age when performed in conjunction with an injection for chronic pain conditions

Injections for Chronic Pain Conditions Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0486-032 Page: 30 of 45

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References

• Abram S. Treatment of lumbosacral radiculopathy with epidural steroids. Anesthesiology. 1999;91:1937-1941.
• Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Interventional treatments for acute and chronic pain: systematic review. https://www.ahrq.gov. Published September 2021. Accessed July 7, 2023.
• Agency for Healthcare Research and Quality (AHRQ). Technology Assessment (ARCHIVED). Pain management injection therapies for low back pain. https://www.ahrq.gov. Published March 20, 2015. Updated July 10, 2015. Accessed July 7, 2023.
• Alvarez D, Rockwell, P. Trigger points: diagnosis and management. American Family Physician. 2002;65(4):653-660.
• Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 31 of 45
• Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
• American Academy of Neurology. Assessment: use of epidural steroid injections to treat lumbosacral pain. https://www.neurology.org. Published March 6, 2007. Updated April 30, 2022. Accessed July 12, 2023.
• American Academy of Orthopedic Surgeons (AAOS). Evidence-Based Guideline. 3rd edition. Treatment of osteoarthritis of the knee. https://www.aaos.org. Published August 31, 2021. Accessed July 12, 2023.
• American Academy of Orthopaedic Surgeons (AAOS). Ortho Info. Cervical radiculopathy (pinched nerve). https://www.aaos.org. Published February 2010. Updated August 2020. Accessed July 12, 2023.
• American Society of Anesthesiologists (ASA). American Society of Anesthesiologists' Position Statement. The medical necessity of anesthesiology services. https://www.asahq.org. Published October 16, 2013. Updated October 17, 2018. Accessed July 12, 2023.
• American Society of Anesthesiologists (ASA). Expert Consensus Document. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. https://www.asahq.org. Published October 13, 1999. Updated October 23, 2019. Accessed July 12, 2023.
• American Society of Anesthesiologists (ASA). Expert Consensus Document. Distinguishing monitored anesthesia care ('MAC') from moderate sedation/analgesia (conscious sedation). https://www.asahq.org. Published October 27, 2004. Updated October 17, 2018. Accessed July 12, 2023.

• https://www.asahq.org. Published October 25, 2005. Updated October 17, 2018. Accessed July 12, 2023.
• American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. https://www.asahq.org. Published October 22, 2005. Updated October 13, 2021. Accessed July 12, 2023.
• Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 32 of 45
• Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
• American Society of Interventional Pain Physicians (ASIPP). American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Epidural interventions in the management of chronic spinal pain. https://www.asipp.org. Published January 2021. Accessed July 12, 2023.
• American Society of Interventional Pain Physicians (ASIPP). American Society of Interventional Pain Physicians (ASIPP) Guidelines. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain. https://www.asipp.org. Published June 2020. Accessed July 12, 2023.
• American Society of Interventional Pain Physicians (ASIPP). American Society of Interventional Pain Physicians (ASIPP) Guidelines. Responsible, safe, and effective use of biologics in the management of low back pain. https://www.asipp.org. Published 2019. Accessed July 12, 2023.
• American Society of Interventional Pain Physicians (ASIPP). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. https://www.asipp.org. Published 2013. Accessed July 12, 2023.
• American Society of Interventional Pain Physicians (ASIPP). ASIPP guidelines for sedation and fasting status of patients undergoing interventional pain management procedures. https://www.asipp.org. Published 2019. Accessed July 12, 2023.
• American Society of Regional Anesthesia and Pain Medicine (ASRA). Complex regional pain syndrome. https://www.asra.com. Published August 6, 2019. Accessed July 12, 2023.
• American Society of Regional Anesthesia and Pain Medicine (ASRA). Consensus practice guidelines on interventions for cervical spine (facet) joint from a multispecialty international working group. https://www.asra.com. Published December 8, 2021. Accessed July 12, 2023.
• American Society of Regional Anesthesia and Pain Medicine (ASRA). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty international working group. https://www.asra.com. Published October 12, 2020. Accessed July 12, 2023.
• American Society of Regional Anesthesia and Pain Medicine (ASRA). Myofascial pain and fibromyalgia syndrome. https://www.asra.com. Published August 6, 2019. Accessed July 12, 2023.
• American Society of Regional Anesthesia and Pain Medicine (ASRA). Sacroiliac joint injections, lateral branch blocks. https://www.asra.com. Published August 6, 2019. Accessed July 12, 2023.

References

1. Epidural corticosteroid injections for radiculopathy and spinal stenosis. Ann Intern Med. 2015;163(5):373-396.
2. Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain - an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:1066-1077.
3. ClinicalKey. Williams K, Guarino A, Raja S. Complex regional pain syndrome. In: Benzon H. Essentials of Pain Medicine. Elsevier; 2018:223-232.e2. https://www.clinicalkey.com. Accessed July 12, 2023.
4. Cohen S, White R, Kurihara C, et al. Epidural steroids, etanercept or saline in subacute sciatica. A multicenter randomized trial. Ann Intern Med. 2012;156:551-559.
5. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38:175- 200.
6. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106(3):591-614.
7. Congress of Neurological Surgeons (CNS). Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low back pain, and lumbar fusion. https://www.cns.org. Published 2006. Updated July 2014. Accessed July 12, 2023.
8. Datta S, Manchikanti L, Falco F, et al. Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: systematic review and update of current evidence. Pain Physician. 2013;16:SE97-SE124.
9. Derby R, Melnik I, Choi J, Lee J. Indications for repeat diagnostic medial branch nerve blocks following a failed first medial branch nerve block. Pain Physician. 2013;16:479-488.
10. ECRI Institute. Clinical Evidence Analysis. VIA Disc Allograft (Vivex Biologics, Inc.) for treating lumbar degenerative disc disease. https://www.ecri.org. Published June 28, 2021. Accessed June 21, 2023.
11. ECRI Institute. Hotline Response (ARCHIVED). Dry needling for managing pain. https://www.ecri.org. Published April 7, 2004. Updated December 5, 2012. Accessed June 21, 2023.
12. ECRI Institute. Hotline Response (ARCHIVED). Epidural steroid injections for treating lumbar radiculopathy. https://www.ecri.org. Published January 24, 2007. Updated December 12, 2012. Accessed June 23, 2023.
13. ECRI Institute. Hotline Response (ARCHIVED). Facet joint injection therapies for treating chronic back pain. https://www.ecri.org. Published January 24, 2007. Updated August 9, 2012. Accessed June 21, 2023.
14. ECRI Institute. Hotline Response (ARCHIVED). Monitored anesthesia care during interventional pain management procedures. https://www.ecri.org. Published July 15, 2016. Accessed June 21, 2023.
15. Friedly J, Comstock B, Turner J, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371:11-21.
16. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11:1149-1168.

1. Gharibo C, Varlotta G, Rhame E, Liu E, Bendo J, Perloff M. Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician. 2011;14:499-511.
2. Hayes, Inc. Evidence Analysis Research Brief. Dry needling of painful myofascial trigger points in adults. https://evidence.hayesinc.com. Published November 15, 2022. Accessed June 21, 2023.
3. Hayes, Inc. Evidence Analysis Research Brief. Nerve blockade for treatment of chronic shoulder pain. https://evidence.hayesinc.com. Published April 7, 2023. Accessed June 29, 2023.
4. Hayes, Inc. Evidence Analysis Research Brief. Nerve blockade of the articular branches of the femoral and obturator nerves for treatment of hip arthritis. https://evidence.hayesinc.com. Published March 20, 2023. Accessed June 29, 2023.
5. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Cluneal nerve block for treatment of low back pain. https://evidence.hayesinc.com. Published September 23, 2021. Accessed June 28, 2023.
6. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Dry needling for pelvic floor muscle dysfunction or pain. https://evidence.hayesinc.com. Published June 23, 2021. Accessed June 21, 2023.
7. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Erector spinae plane block for management of chronic thoracic pain. https://evidence.hayesinc.com. Published April 30, 2021. Accessed June 29, 2023.
8. Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Sacroiliac joint injections with corticosteroids for treatment of chronic low back pain.https://evidence.hayesinc.com. Published April 18, 2022. Accessed June 28, 2023.
9. Hayes, Inc. Evolving Evidence Review. Epidural steroid injections for the treatment of thoracic spine pain. https://evidence.hayesinc.com. Published July 23, 2021. Updated March 16, 2023. Accessed June 29, 2023.
10. Hayes, Inc. Evolving Evidence Review. Middle cluneal nerve block for treatment of low back pain. https://evidence.hayesinc.com. Published January 4, 2022. Updated April 4, 2023. Accessed June 28, 2023.
11. Hayes, Inc. Evolving Evidence Review. Superior cluneal nerve block for treatment of low back pain. https://evidence.hayesinc.com. Published December 30, 2021. Accessed June 28, 2023.
12. Hayes, Inc. Health Technology Assessment. Dry needling for indications other than neck or trapezius muscle pain in adults. https://evidence.hayesinc.com. Published June 29, 2023. Accessed July 5, 2023.
13. Hayes, Inc. Health Technology Assessment. Dry needling for mechanical neck and/or trapezius muscle pain in adults. https://evidence.hayesinc.com. Published May 18, 2023. Accessed June 21, 2023.
14. Hayes, Inc. Health Technology Assessment. Ganglion impar block or radiofrequency thermocoagulation for treatment of chronic coccydynia. https://evidence.hayesinc.com. Published July 21, 2022. Accessed June 29, 2023.
15. Hayes, Inc. Health Technology Assessment. Genicular nerve block for the management of knee pain. https://evidence.hayesinc.com. Published June 24, 2020. Updated May 15, 2023. Accessed June 29, 2023.

Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 37 of 45
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

1. Hayes, Inc. Health Technology Assessment. Sacroiliac joint injection with corticosteroids for treatment of sacroiliac joint and low back pain. https://evidence.hayesinc.com. Published June 13, 2023. Accessed June 28, 2023.
2. Hayes, Inc. Health Technology Brief (ARCHIVED). Epidural injection of Enbrel (etanercept; Immunex Corp.) for treatment of low back pain due to lumbar disc disease. https://evidence.hayesinc.com. Published December 23, 2013. Updated December 9, 2015. Accessed June 28, 2023.
3. Hayes, Inc. Medical Technology Directory. Epidural steroid injections for cervical radiculopathy. https://evidence.hayesinc.com. Published February 28, 2019. Updated February 3, 2022. Accessed June 29, 2023.
4. Hayes, Inc. Medical Technology Directory (ARCHIVED). Comparative effectiveness review of dry needling for indications other than neck or trapezius muscle pain in adults. https://evidence.hayesinc.com. Published June 22, 2017. Updated June 30, 2021. Accessed June 21, 2023.
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72. Kennedy D, Zheng P, Smuck M, McCormick Z, Huynh L, Schneider B. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 39 of 45 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.injections in patients with lumbar radicular pain due to intervertebral disc herniation. Spine J. 2018;18:29-35.
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Manchikanti L, Cash K, Pampati V, Wargo B, Malla Y. A randomized, double- blind active control trial of fluoroscopic cervical interlaminar epidural Injections for Chronic Pain Conditions Effective Date: 07/27/2023 Revision Date: 07/27/2023 Review Date: 07/27/2023 Policy Number: HUM-0486-032 Page: 40 of 45 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. injections in chronic pain of cervical disc herniation: results of a 2-year follow- up. Pain Physician. 2013;16:465-478.

82. Manchikanti L, Malla Y, Wargo B, Cash K, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012;15:131-140.
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90. MCG Health. Nerve block or neurolysis, celiac plexus or splanchnic nerve. 27th edition. https://www.mcg.com. Accessed June 19, 2023.
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Injections for Chronic Pain Conditions Effective Date: 07/27/2023
Revision Date: 07/27/2023
Review Date: 07/27/2023
Policy Number: HUM-0486-032 Page: 45 of 45
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