Sunflower Health Plan Caudal or Interlaminar Epidural Steroid Injections (PDF) Form

Epidural steroid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain, despite inconsistent results as well as heterogeneous populations and interventions in randomized trials. Epidural injections are performed utilizing three approaches in the lumbar spine: caudal, interlaminar, and transforaminal. Generally, candidates for epidural steroid injection are individuals who have acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with significant impairment in activities of daily living. Note: For guidelines for transforaminal ESIs, reference CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections. Policy/Criteria It is the policy of health plans affiliated with Centene Corporation® that invasive pain management procedures performed by a physician are medically necessary when the relevant criteria are met, onl y one procedure is performed per visit, with imaging guidance (except in rare instances, with documented justification), and t he member/enrollee is not currently being treated with full anticoagulation therapy. I f on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure. Discontinuing anti-platelet therapy is a clinical decision balancing risks and benefits of the procedure on therapy, versus the underlying medical condition if not treated appropriately.23 I. It is the policy of health plans affiliated with Centene Corporation® that caudal or interlaminar epidural steroid injections (ESIs) are medically necessary for the following indications: A. One caudal or interlaminar ESI for acute pain management (pain lasting < 3 months) when all of the following are met: 1. There is severe radicular pain that interferes substantially with activities of daily living (ADLs); 2. Severe pain persists after treatment with nonsteroidal anti-inflammatory drugs (NSAID) and/or opiates (both ≥ 3 days or contraindicated/not tolerated); 3. The member/enrollee cannot tolerate chiropractic or physical therapy and the injection is intended as a bridge to therapy. B. Initial ESI for chronic pain, all of the following: 1. Request is for one caudal or interlaminar ESI at one level in the cervical, thoracic or lumbar region; 2. Persistent radicular pain has been caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae, as confirmed by physical exam and imaging; 3. Pain interferes with ADLs and has lasted for at least 3 months; Page 1 of 8 CLINICAL POLICY Caudal or Interlaminar Epidural Steroid Injections 4. The member/enrollee has failed to respond to conservative therapy including all of the following: a. ≥ 6 weeks chiropractic, physical therapy or prescribed home exercise program; b. NSAID ≥ 3 weeks or NSAID contraindicated or not tolerated; c. ≥ 6 weeks activity modification. C. Second caudal or interlaminar ESI for chronic pain that did not improve from the first ESI, all of the following: 1. Request is for an ESI at one level in the cervical, thoracic or lumbar region; 2. At least 2 weeks have passed since the first ESI. D. Subsequent caudal or interlaminar ESI for recurrence of chronic pain that had improved from the first or second ESI, all of the following: 1. Initial injection(s) led to ≥ 50% relief and functional improvement for at least 2 months; 2. At least 2 months have passed since the last ESI; 3. Less than 4 injections have been administered within 12 months; 4. Less than 12 months have elapsed since the initial injection at the level requested. II. It is the policy of health plans affiliated with Centene Corporation that a third or subsequent caudal or interlaminar ESI for chronic pain that did not improve from the first two ESIs is considered not medically necessary because effectiveness has not been established. III.It is the policy of health plans affiliated with Centene Corporation that continuation of injections beyond 12 months or more than 4 therapeutic injections is considered not medically necessary because effectiveness and safety have not been established. When more definitive therapies cannot be tolerated or provided, consideration will be made on a case by case basis. IV. It is the policy of health plans affiliated with Centene Corporation that caudal or interlaminar ESI for any other indication or location is considered not medically necessary because effectiveness has not been established. Background There is much debate on the efficacy and medical necessity of multiple interventions for managing spinal pain. Epidural glucocorticoid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain despite inconsistent results as well as heterogeneous populations and interventions in randomized controlled trials (RCTs). Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal.2 Generally, candidates for epidural steroid injection are individuals who have acute radicular symptoms or neurogenic claudication unresponsive to traditional analgesics and rest, with significant impairment in activities of daily living. Epidural steroid injections have been used in the treatment of spinal stenosis for many years, and no validated long-term outcomes have been reported to substantiate their use. However, significant improvement in pain scores have been reported at 3 months after injection. Page 2 of 8 CLINICAL POLICY Caudal or Interlaminar Epidural Steroid Injections Zhai et al conducted a meta-analysis to assess the effects of various surgical and nonsurgical modalities, including epidural injections, used to treat lumbar disc herniation (LDH) or radiculitis. A systemic literature review identified RCTs that compared the use of local anesthetic with and without steroids. The outcomes included pain relief, functional improvement, opioid intake, and therapeutic procedural characteristics. The reviewers concluded the meta-analysis confirms that epidural injections of local anesthetic with or without steroids have beneficial but similar effects in the treatment of patients with chronic low back and lower extremity pain.1 Results of a 2-year follow-up of 3 randomized, double-blind, controlled trials, with a total of 360 patients with chronic persistent pain of disc herniation receiving either caudal, lumbar interlaminar or transforaminal epidural injections, showed similar efficacy of the 3 techniques with local anesthetic alone or local anesthetic with steroid.2 Caudal and interlaminar trials used in the assessment showed some superiority of steroids over local anesthetic at 3 and 6 month follow-up. Interlaminar with steroids were superior to transforaminal at 12-months.2 Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT® Codes 62320 62321 62322 62323 62324 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 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 (i.e., fluoroscopy or CT) 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 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 (i.e., fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, Page 3 of 8 CLINICAL POLICY Caudal or Interlaminar Epidural Steroid Injections CPT® Codes 62325 62326 62327 antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 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, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT) 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 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 (i.e., fluoroscopy or CT) HCPCS Codes N/A Other spondylosis with radiculopathy, cervical region Other spondylosis with radiculopathy, cervicothoracic region Other spondylosis with radiculopathy, thoracic region Other spondylosis with radiculopathy, thoracolumbar region Other spondylosis with radiculopathy, lumbar region Other spondylosis with radiculopathy, lumbosacral region Spinal Stenosis ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code requiring an additional character Code M47.22 M47.23 M47.24 M47.25 M47.26 M47.27 M48.00 through M48.08 M50.10 through M50.13 M51.14 through M51.17 M54.12 M54.13 M54.14 M54.15 M54.16 M54.17 Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with radiculopathy Radiculopathy, cervical region Radiculopathy, cervicothoracic region Radiculopathy, thoracic region Radiculopathy, thoracolumbar region Radiculopathy, lumbar region Radiculopathy, lumbosacral region Cervical disc disorder with radiculopathy Page 4 of 8 CLINICAL POLICY Caudal or Interlaminar Epidural Steroid Injections Code M54.5 M54.6 M96.1 Low back pain Pain in thoracic spine Postlaminectomy syndrome, not elsewhere classified Reviews, Revisions, and Approvals Caudal and interlaminar ESI criteria reviewed in CP.MP.118 Split from CP.MP.118 Injections for Pain Management. No criteria changes. In section D regarding second or subsequent ESI for chronic pain that improved from the diagnostic injections, changed requirement for 3 months having passed from the previous injection to 2 months. Anticoagulation indication moved to policy/criteria section as it is applicable to all injections in this policy. References reviewed and updated In policy statement, changed “with or without radiographic guidance” to “with imaging, (except in rare instances, with documented justification).” Added, “Request is not for cervical interlaminar ESI above C7” to B.5, C.3 and D.5. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review. Removed “Request is not for cervical interlaminar ESI above C7” from B.5, C.3 and D.5. Annual review. Note added regarding guidelines for transforaminal ESIs. Background updated with no impact on criteria. References reviewed and updated. Revision Date 04/18 08/18 Approval Date 04/18 08/19 08/19 06/20 07/21 07/20 07/21 09/21 09/21 07/22 07/22