Sunflower Health Plan Intradiscal Steroid Injections for Pain Management (PDF) Form

Intradiscal steroid injections involve injecting glucocorticoids directly into the spinal disc that has been identified as the source of pain. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that intradiscal steroid injections are considered not medically necessary because effectiveness has not been established. The published literature suggests both positive and negative results. Further research is being done to determine the safety and efficacy of injecting steroids directly into the disc. Background There is limited and conflicting evidence regarding the effectiveness of intradiscal glucocorticoids for low back pain.1 In patients with magnetic resonance imaging (MRI) evidence of degenerative disc disease and a positive response to discography, two trials found no difference between intradiscal steroid and control injection (saline or local anesthetic).1 A third trial found that in patients with degenerative disc disease who failed an epidural steroid injection, intradiscal steroid injection was superior to discography alone only in the subgroup of patients with inflammatory endplate changes on MRI.1 However, outcomes were not well defined in this trial, and levels of statistical significance were poorly reported. Based on these trials, the American Pain Society guideline recommends against intradiscal glucocorticoid injection for presumed discogenic pain.2 A randomized trial of 135 patients with active discopathy treated with a glucocorticoid intradiscal injection during discography or discography alone, found that back pain was improved at one month in the intradiscal injection group, but the effect was not present at 12 months.3 Secondary outcomes such as activity limitations, use of analgesics, quality of life, and anxiety and depression did not differ between the treatment and control groups at either evaluated time point.3 The use of intradiscal steroid injections is also debated because intradiscal steroid may cause discitis, progression of disc degeneration, and calcification of the intervertebral disc.1 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. Page 1 of 4 CLINICAL POLICY Intradiscal Steroid Injections Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. Unlisted procedure, spine CPT® Codes 22899 HCPCS Codes N/A ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code requiring an additional character ICD -10 -CM Code N/A Reviews, Revisions, and Approvals Policy split from CP.MP.118 Injections for Pain Management. Background updated. References and coding reviewed. Specialty reviewed completed. References reviewed and updated. Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, reformatted and updated. Replaced “member” with “member/enrollee” in all instances. Specialist review. Annual Review. Criteria section updated to single spacing. Background updated with no impact on criteria. References reviewed and updated. Specialist reviewed. Revision Date 08/18 Approval Date 08/18 08/19 07/20 08/21 08/19 08/20 08/21 08/22 08/22