Latest Review Date: November 2024

 

Category:  Surgical                                                                

POLICY:

Epidural steroid injections (with or without an anesthetic agent) performed with imaging guidance may be considered medically necessary when:

• Pain symptoms have been evaluated by physical examination, EMG, or radiographic imaging; and
• Except in cases of acute disc injury documented on imaging studies, patient’s pain symptoms have failed to improve after at least two weeks of conservative therapy*

Up to 6 epidural injections within a 12-month period may be considered medically necessary. Bilateral injections performed on a single level are counted as one injection towards the maximum.

Epidural steroid injections (with or without an anesthetic agent) performed without imaging guidance are considered investigational.

Multiple epidural injections performed at the same spinal level through various approaches (i.e., interlaminar or transforaminal) on the same date of service are considered investigational.

Simultaneous treatment of 2 vertebral levels may be considered medically necessary if criteria are met at each level.

Simultaneous treatment of more than 2 vertebral levels is considered investigational.

Additional injections may be covered on an individual case basis if the patient sustains an additional acute injury. Medical records must clearly document date, type, and location of injury. 

The use of fluorography (imaging of the epidural space) as a component of epidural steroid injections is considered investigational.

Intradiscal injections of steroids or other substances are considered investigational.

Above coverage requirements do not apply to epidural injections performed for pain management during labor/delivery or surgical procedures or for post-operative pain.

**Conservative therapy is the use of structured physician-directed modalities which may include: prescription strength analgesics/anti-inflammatory medications if not contraindicated; participation in therapeutic physical medicine modality(ies) and/or manipulations when rendered by an eligible provider (including active exercise).

Note: For trigger point injections, see medical policy #739 Trigger Point Injections. For dry needling, see medical policy #740 Dry Needling of Trigger Points.

DESCRIPTION OF PROCEDURE OR SERVICE:

Epidural steroid injections (ESIs) are a treatment for back pain that has not responded to conservative measures. Local steroid injections may improve pain by reducing inflammation, thus relieving pressure on nerve roots or other structures that may be the origin of pain.

Back Pain

Back pain is an extremely common condition. Most episodes are self-limited and will resolve within 1 month, but a small percentage will persist and become chronic. Patients with chronic back pain may suffer from a serious disability and may use a high volume of medical services. Despite high utilization, many patients with chronic back pain do not improve with available treatments, including surgical interventions. Therefore, there is a high unmet need to determine the efficacy of different treatments for chronic back pain and to determine which patient populations may benefit from specific interventions. In addition, there has been a proliferation of new technologies, combined with large increases in the number of patients treated and in the intensity of treatment. Therefore, there is a concern for the over-treatment of patients who may not benefit from interventions for back pain.

Lumbar or Cervical Radiculopathy

Back pain can result from a variety of underlying causes. Radiculopathy is a subset of back pain that is associated with irritation of 1 or more spinal nerve roots. Symptoms of lumbar radiculopathy, which is sometimes known as sciatica, include pain that radiates down the leg to below the knee, numbness, muscle weakness, and lack of reflexes in a dermatomal distribution. Most patients with radiculopathy respond to conservative care with a resolution of their symptoms within several weeks to months following onset. In a subset of patients, symptoms and signs of progressive muscle weakness prompt a more aggressive intervention to prevent permanent dysfunction. In other patients, symptoms persist despite conservative management, without progression of neurologic signs, and further treatment options are sought for pain relief.

Spinal Stenosis

Spinal stenosis is another common source of back pain. Spinal stenosis is caused by the narrowing of the spinal canal due to degenerative changes, leading to impingement of the spinal cord and the spinal nerve roots. Symptoms of spinal stenosis can include back pain, leg pain with exertion (neurogenic claudication), muscle weakness, and sensory deficits. The definitive treatment for spinal stenosis is surgery, which includes decompression of the spinal canal with or without spinal fusion. Epidural steroids may reduce inflammation from pressure on the spinal cord, and thus reduce symptoms of compression.

Nonspecific Low Back Pain

Nonspecific low back pain, sometimes called mechanical low back pain, is diagnosed when no specific etiology of pain can be identified. Although the etiology of nonspecific low back pain is uncertain, many experts feel that the pain is of discogenic origin or due to the painful movement of the vertebrae. In these instances, epidural steroid injections (ESIs) may reduce swelling of the vertebral disc and/or surrounding structures, leading to pain relief.

Treatment

Regardless of specific etiology, conservative management is the first-line treatment for most patients with neck or back pain. Nonsteroidal anti-inflammatory drugs or other analgesics are used for symptom relief. These agents should be used for at least several weeks at a dose sufficient to induce a therapeutic response. Duloxetine or tramadol are recommended second-line pharmacologic therapies by the American College of Physicians. Additionally, modification of activity in conjunction with some form of exercise therapy is frequently prescribed early in the course of symptoms and typically involves a physical therapist. For patients with persistent nonradicular back pain, guidelines recommend interdisciplinary rehabilitation, which is defined as an integrated approach using physical rehabilitation in conjunction with a psychological or psychosocial intervention.

For patients who fail conservative therapy, a number of interventional therapies are available, which range from minimally invasive procedures, such as injections, to major surgeries, such as spinal decompression with fusion. Injections can be given in different locations (e.g., soft tissues, intraspinal, sacroiliac joints) and can use different therapeutic agents (e.g., botulinum toxin, steroids, proteolytic enzymes). Other interventional techniques include radiofrequency ablation, prolotherapy, and chemonucleolysis. Most of these nonsurgical interventions do not have high-quality evidence demonstrating their efficacy. A number of surgical interventions are available, such as discectomy and spinal fusion, each of which can be performed by a variety of techniques. The decision to undertake surgery is best made in the setting of shared decision making between the patient and surgeon, with thorough consideration given to the risks and benefits of surgery.

Epidural Steroid Injections

Epidural injection therapy is one of several second-line therapies available for patients who fail conservative treatment and is one of the most common modalities used in this group of patients. Epidural steroid injections (ESIs) are performed by inserting a needle into the space between the dura and ligamentum flavum and injecting a steroid preparation. There is considerable variability in the technical aspects of epidural injections. Several different approaches may be used for entering the epidural space (translaminar, transforaminal, caudal). In addition, ESIs may be administered with or without fluoroscopic guidance. For example, a national survey published in 2002 reported that 30% of academic institutions and 77% of private practices use fluoroscopy. Some authors have estimated that lack of correct needle position in the epidural space may occur in 25% or more of injections administered. Variability of technique may also involve factors such as the depth of injection into the epidural space, volume of injectate, and the filling patterns of the injectate.

Treatment is generally given as one to three injections, each performed at least one month apart. Some experts recommend no more than 3 injections in a 12-month period, owing to concerns about the adverse events of chronic steroid administration, both locally and systemically. However, other experts believe that up to six injections per year are safe.

Intradiscal injection is performed for both diagnostic and therapeutic purposes. For diagnostic reasons, a local anesthetic is used to temporarily block pain within a disc and determine if the pain is coming from that particular disc. For therapeutic reasons, a steroid is injected to decrease inflammation within a disc. The steroid usually takes two to three days to relieve pain.

Note: Facet joint injections are addressed separately in medical policy, #141 Treatment Modalities for Facetogenic Pain.

KEY POINTS:

Summary of Evidence

This evidence has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through September 12, 2024.

For individuals who have lumbar or cervical radiculopathy who receive ESI, the evidence includes many small RCTs and a number of systematic reviews of these RCTs. The relevant outcomes are symptoms, functional outcomes, health status measures, QOL, medication use, and treatment-related morbidity. The evidence base lacks large-scale, high-quality trials and has a high degree of variability among the available trials in terms of patient populations, epidural injection techniques, and comparison treatments. The results of individual trials are mixed, with some reporting significant benefits for the ESI group and others reporting no benefit. Most systematic reviews did not perform pooled analyses due to the heterogeneity of trials. In the two reviews that reported quantitative results, short-term pain relief at up to six months follow-up was superior in patients treated with epidural steroids. None of the analyses reported long-term benefits for treatment with ESIs. Adverse events were generally mild but not well reported in these trials. Serious adverse events can occur, but their rate is unknown. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have spinal stenosis who receive ESIs, the evidence includes a moderately large RCT, a few small RCTs, and systematic reviews of these RCTs. The relevant outcomes include symptoms, functional outcomes, health status measures, QOL, medication use, and treatment-related morbidity. The largest RCT and the majority of smaller trials did not report a benefit for ESIs. The evidence is insufficient to determine the effects of technology on health outcomes.

For individuals who have nonspecific low back pain who receive ESIs, the evidence includes a number of small RCTs and systematic reviews of these RCTs. The relevant outcomes include symptoms, functional outcomes, health status measures, QOL, medication use, and treatment-related morbidity. Most trials were of low quality and did not report a benefit for ESIs. The evidence is insufficient to determine the effects of the technology on health outcomes.

Intradiscal Injections

There is no convincing evidence that intradiscal glucocorticoids are effective for low back pain. In patients with 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). 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. 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 chronic low back pain.

Tumor necrosis factor (TNF)-alpha has been implicated in the pathogenesis of radiculopathy and discogenic back pain. A small pilot study showed that intradiscal injections of etanercept (interferes with TNF-alpha) did not improve pain or disability scores for patients with lumbosacral radiculopathy or chronic discogenic low back pain.

Methylene blue is a compound used as a dye or stain which has been studied for various therapeutic purposes. A randomized trial (n = 72) found intradiscal injection of methylene blue for patients with discography-positive, presumed discogenic back pain associated with large improvements in pain (about 40 points on a 100-point pain scale) and function (about 35 points on the 0 to 100 Oswestry Disability Index) compared with a placebo intradiscal injection, with no adverse events such as increased pain, radiculopathy, or infection. However, a smaller (n = 24) randomized trial found no difference between intradiscal methylene blue versus a placebo intradiscal injection in pain or function after one month, and over half of the patients treated with methylene blue reported severe pain immediately after the injection. Longer-term results are not yet available, although the trial is designed to follow patients for one year.

Kallewaard and colleagues stated that an estimated 40 % of chronic lumbosacral spinal pain is attributed to the discus intervertebralis. Degenerative changes following loss of hydration of the nucleus pulposus lead to circumferential or radial tears within the annulus fibrosus. Annular tears within the outer annulus stimulate the ingrowth of blood vessels and accompanying nociceptors into the outer and occasionally inner annulus. Sensitization of these nociceptors by various inflammatory repair mechanisms may lead to chronic discogenic pain.  The current criterion standard for diagnosing discogenic pain is pressure-controlled provocative discography using strict criteria and at least one negative control level. The strictness of criteria and the adherence to technical detail will allow an acceptable low false-positive response rate. The most important determinants are the standardization of pressure stimulus by using a validated pressure monitoring device and avoiding overly high dynamic pressures by the slow injection rate of 0.05 mL/s. A positive discogram requires the reproduction of the patient's typical pain at an intensity of greater than 6/10 at a pressure of less than 15 psi above opening pressure and at a volume less than 3.0 ml. Perhaps the most important and defendable response is the failure to confirm the discus is symptomatic by not meeting this strict criteria. Various interventional treatment strategies for chronic discogenic LBP unresponsive to conservative care include reduction of inflammation, ablation of intradiscal nociceptors, lowering intra-nuclear pressure, removal of herniated nucleus, and radiofrequency ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal criteria for a positive treatment advice. In particular, single-needle radiofrequency thermo-coagulation of the discus is not recommended for patients with discogenic pain (2 B-). Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans meets the (2 B+) level for endorsement. The authors concluded that there is currently insufficient proof to recommend intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty. It is advised that ozone discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a study protocol; future studies should include more strict inclusion criteria.

In a systematic review and meta-analysis of RCTs, Magalhaes et al evaluated the therapeutic results of percutaneous injection of ozone for LBP secondary to disc herniation. A comprehensive literature search was conducted using all electronic databases from 1966 through September 2011. The quality of individual articles was assessed based on the modified Cochrane review criteria for randomized trials and criteria from the Agency for Healthcare Research and Quality. The outcome measure was short-term pain relief of at least six months or long-term pain relief of more than six months. A total of eight observational studies were included in the systematic review and four randomized trials in the meta-analysis. The indicated level of evidence for long-term pain relief was II-3 for ozone therapy applied intradiscally and II-1 for ozone therapy applied paravertebrally. The grading of recommendation was 1C for intradiscal ozone therapy and 1B for paravertebral ozone therapy. The authors concluded that ozone therapy appears to yield positive results and low morbidity rates when applied percutaneously for the treatment of chronic LBP. The main drawbacks of this review were the lack of precise diagnosis and the frequent use of mixed therapeutic agents. The meta-analysis included mainly active-control trials. No placebo-controlled trial was found.

Clinical Input Received from Physician Specialty Societies and Academic Medical Centers

Epidural Injections

There are several aspects of epidural steroid injection therapy that are not standardized. In response to requests, input was received from 5 academic medical centers and 6 specialty societies while this policy was in development in 2014. Consensus was reached among reviewers that: treatment of cervical radiculopathy is medically necessary with the same criteria as for lumbar radiculopathy; the minimum period of time for conservative therapy should be 4 weeks or less; fluoroscopic guidance should be used in all cases of epidural steroid injections (ESI); and, fluorography imaging of the epidural spaces investigational. There was mixed input on the optimal timing to assess response, the number of levels that should be treated at one time, and the maximum number of injections to be given in one year. Some experts agree that no more than three injections should be given in one year, but other experts believe that more than three per year can be used safely. None of the expert opinion supported more than six injections given over a 12-month period.

Practice Guidelines and Position Statements

American Academy of Neurology

In 2007, the American Academy of Neurology published a guideline on the use of epidural steroids for lumbosacral radiculopathy; this guideline was reaffirmed in 2022. This guideline made the following recommendations:

• “[E]pidural steroid injections may result in some improvement in radicular lumbosacral pain when determined between 2 and 6weeks following the injection, compared to control treatment (Level C, Class I-III). The average magnitude of effect is small, and the generalizability of the observation is limited by the small number of studies, limited to highly selected patient populations, the few techniques and doses studied, and variable comparison treatments.”

• “[I]n general, epidural steroid injections for radicular lumbosacral pain have shown no impact on average impairment of function, on need for surgery, or on long-term pain relief beyond 3 months. Their routine use for these indications is not recommended (Level B, Class I-III).”

• “[T]here is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain (Level U).”

American Association of Neurological Surgeons

In 2014, the guidelines on the performance of fusion procedures for degenerative disease of the lumbar spine from the American Association of Neurological Surgeons stated that lumbar ESIs are an option for short-term relief of chronic low back pain without radiculopathy in patients with degenerative disease of the lumbar spine (level III evidence). Caudal ESIs are an option for reducing low back pain without radiculopathy of greater than 6 weeks in duration in patients with degenerative disease of the lumbar spine (level III evidence).

American College of Physicians et al

In 2007, the American College of Physicians and the American Pain Society issued guidelines on the diagnosis and treatment of low back pain, which stated: “Patients with persistent low back pain and signs and symptoms of radiculopathy or spinal stenosis should be evaluated with MRI (preferred) or CT [computed tomography] only if they are potential candidates for surgery or ESI. (Strong recommendation, moderate-quality evidence).” Portions of these guidelines were updated in 2017, but there was no discussion on ESI use.

American Pain Society

In 2009, the American Pain Society published guidelines on the use of interventional therapies for low back pain, 1, based on a systematic review of the evidence published in the same year. These guidelines made the following recommendations on ESIs:

• “In patients with persistent radiculopathy due to herniated lumbar disc, it is recommended that clinicians discuss risks and benefits of epidural steroid injections as an option (weak recommendation, moderate-quality evidence). It is recommended that shared decision making regarding ESI include a specific discussion about inconsistent evidence showing moderate short-term benefits, and lack of long-term benefits.”
• There is “insufficient evidence … to reliably judge benefits and harms” of ESI for spinal stenosis.
• “There is insufficient evidence to adequately evaluate benefits of local injections, botulinum toxin injection, ESI, intradiscal electrothermal therapy (IDET), therapeutic medial branch block, radiofrequency denervation, sacroiliac joint steroid injection, or intrathecal therapy with opioids or other medications for nonradicular back pain.”

American Society of Anesthesiologists

In 2010, the guidelines on chronic pain management from the American Society of Anesthesiologists recommended that transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before injecting therapeutic substances. Image guidance might be considered for interlaminar epidural injections to confirm correct needle position and spread of contrast before injecting therapeutic substance.

American Society of Interventional Pain Physicians

In 2021, the American Society of Interventional Pain Physicians published an updated guideline on the use of epidural injections in the management of chronic spinal pain.

For patients with disc herniation, the following recommendations were made:

• Based on relevant, high-quality trials of fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, "the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."

• "For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness."

For patients with spinal stenosis, the following recommendations were made: "based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement."

For patients with axial discogenic pain, "The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids."

North American Spine Society (NASS)

The North American Spine Society (NASS) has released multiple clinical guidelines for the management of back pain. In 2020, the NASS released comprehensive guidelines on the diagnosis and treatment of low back pain. This guideline was last updated in 2021. The NASS concluded there is insufficient evidence for or against the use of caudal ESI for discogenic low back pain or interlaminar ESI for axial low back pain based on a review of the literature (grade I recommendation).

American Society of Pain and Neuroscience

A 2022 American Society of Pain and Neuroscience (ASPN) guideline provides recommendations for the use of epidural steroid injections in the treatment of low back pain. Relevant recommendations are provided in the table below.

ASPN Back Consensus Group Recommendations for Epidural Steroid Injections

Recommendation	Grade	Evidence Level	Level of certainty
Interlaminar epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention	Aa	1-Abb	Highc
Transforaminal epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention
Caudal epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention when interlaminar or transforaminal approaches are not feasible
Use of either steroid or local anesthetic or the two classes of medication in combination for use in epidural injections for treatment of low back and radicular pain originating from disc disease, spinal stenosis and for chronic back/leg pain after surgical intervention

Adapted from Sayed et al (2023).

^aGrade A: The ASPN Back Group recommends the service. There is high certainty that the net benefit is substantial.

^bLevel 1-A evidence: At least one controlled and randomized clinical trial, properly designed.

^cHigh level of certainty: The available evidence includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

In 2022, ASPN also released consensus guidance regarding best practices for minimally invasive lumbar spinal stenosis treatment. The ASPN guideline outlines peer-reviewed literature and provides the following consensus recommendations. It is important to note that the guidelines state that the methodology among trials analyzed varied widely as did outcome measures, length of follow-up, and comparators, and that as a result, treatment efficacy for the modality of lumbar epidural steroid injections has been difficult to determine. These recommendations also pertain to clinically significant lumbar spinal stenosis (which is more specific than general spinal stenosis that this policy pertains to, and which can happen in any part of your spine) and neurogenic claudication that fails to be managed with noninterventional methods of pain relief.

• "Consensus Point 12: Epidural steroid injections are recommended in the algorithm for the treatment of symptomatic lumbar spinal stenosis. Grade B; Level of certainty high; Level of evidence I-A (meaning that there was at least 1 RCT included in the analysis)
• "Consensus Point 13: Epidural steroid injection may be repeated when a patient has significant temporary improvement in symptoms. Be aware that the number and frequency of injections may be limited by insurance and payer rules and regulations. Grade B; Level of certainty moderate; Level of evidence I-B (meaning only non-randomized clinical trials were included in the analysis)

U.S Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Epidural injections of corticosteroids, epidural steroid injections, ESIs, intradiscal injections, myofascial pain

APPROVED BY GOVERNING BODIES:

Steroids are not FDA approved for use as epidural injections, such use represents off-label use of an FDA approved medication. The specific preparations used for epidural injections are steroids added to a sterile saline solution, which are prepared by a compounding pharmacy.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT Codes:  

20999	Unlisted procedure, musculoskeletal system, general
22899	Unlisted procedure, spine
62320	Injection(s), of diagnostic or therapeutic substance(s) (e.g. 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
62321	; with imaging guidance
62322	Injection(s), of diagnostic or therapeutic substance(s) (e.g. 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
62323	; with imaging guidance (i.e. fluoroscopy or CT)
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)
77003	Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

 

REFERENCES:

1. American Academy of Neurology (AAN). AAN Summary of Evidence-Based Guidelines for Clinicians: Use of epidural steroid injections to treat lumbosacral radicular pain. 2007; https://www.aan.com/Guidelines/Home/GetGuidelineContent/250.
2. Arirachakaran A, Siripaiboonkij M, Pairuchvej S, et al. Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: A systematic review and meta-analysis of randomized controlled trials. Eur J Orthop Surg Traumatol, 2018 May 31;28(8).
3. Benyamin RM, Manchikanti L, Parr AT, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. Jul-Aug 2012; 15(4):E363-404.
4. Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. Jan-Feb 2009; 12(1):137-157.
5. Benzon HT, Connis RT, De Leon-Casasola OA, et al. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. Apr 2010; 112(4): 810-33.
6. Bhatia A, Flamer D, Shah PS, et al. Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis. Anesth Analg. Mar 2016; 122(3):857-870.
7. Bise S, Pesquer L, Feldis M, et al. Comparison of three CT-guided epidural steroid injection approaches in 104 patients with cervical radicular pain: Transforaminal anterolateral, posterolateral, and transfacet indirect. Skeletal Radiol., 2018 Jul 23; 47(12).
8. Borton ZM, Oakley BJ, Clamp JA, et al. Cervical transforaminal epidural steroid injections for radicular pain : a systematic review. Bone Joint J. May 2022; 104-B(5): 567-574.
9. Centers for Disease Control Prevention. Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a single compounding pharmacy - United States, 2012. MMWR Morb Mortal Wkly Rep. Oct 19 2012; 61(41):839-842.
10. Chou R, Atlas SJ, Stanos SP et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine 2009; 34(10):1078-1093.
11. Chou R, Loeser JD, Owens DK et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009; 34(10):1066-1077.
12. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. Oct 02 2007;147(7):478-491.
13. Cohen SP, Hayek S, Semenov Y, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. Nov 2014; 121(5):1045-1055.
14. Deer TR, Grider JS, Pope JE, et al. Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2022; 15: 1325-1354.
15. Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician. Jul-Aug 2012; 15(4):E405-434.
16. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. Jul 3 2014; 371(1):11-21.
17. Friedly JL, Comstock BA, Turner JA, et al. Long-term effects of repeated injections of local anesthetic with or without corticosteroid for lumbar spinal stenosis: a randomized trial. Arch Phys Med Rehabil. Aug 2017; 98(8):1499-1507.e1492.
18. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
19. Koes BW, Scholten RJ, Mens JM, et al. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain. Dec 1995; 63(3):279-288.
20. Manchikanti L, Buenaventura RM, Manchikanti KN, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. May-Jun 2012; 15(3):E199-245.
21. Manchikanti L, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. Jan 2021; 24(S1): S27-S208.
22. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care: Diagnosis and treatment of low back pain. 2020; https://www.spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LowBackPain.pdf.
23. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. Dec 18 2012; 157(12):865-877.
24. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Apr 04 2017; 166(7):  514-530.
25. Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. May 2015; 122(5):974-984.
26. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022; 15: 3729-3832.
27. Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: A randomized clinical trial. JAMA Netw Open, 2019 Jan 16;2(1).
28. Smith, CC, McCormick ZL, Mattie, R, et al. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: A comprehensive review of the published data. Pain Med. Mar 01 2020; 21(3): 472-487.
29. Staal JB, de Bie R, de Vet HC, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. Jul 16 2008; (3):CD001824.
30. US Food and Drug Administration. Epidural corticosteroid injection: drug safety communication - risk of rare but serious neurologic problems. 2014; //www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm394530.htm.
31. Verheijen EJA, Bonke CA, Amorij EMJ, et al. Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis. Eur Spine J. May 11 2021.
32. Watters WC, 3rd, Resnick DK, Eck JC, et al. 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. J Neurosurg Spine. Jul 2014;21(1):79-90.
33. Yang S, Kim W, Kong HH, et al. Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: A meta-analysis of randomized controlled trials. Medicine (Baltimore). Jul 24 2020; 99(30): e21283.

POLICY HISTORY:

Medical Policy Group, September 2006 (2)

Medical Policy Group, February 2007

Medical Policy Administration Committee, February 2007

Medical Policy Group, March 2007 (2)

Medical Policy Administration Committee, April 2007

Available for comment May 8-June 21, 2007

Medical Policy Group, June 2007 (2)

Medical Policy Group, July 2007 (2)

Medical Policy Administration Committee, July 2007

Available for comment July 16-September 3, 2007

Medical Policy Group, April 2009 (2)

Medical Policy Administration Committee, May 2009

Available for comment April 14-May 28, 2009

Medical Policy Panel, February 2010

Medical Policy Group, November 2010 Code update only

Coding update, December 2010 (1): Verbiage update to 77003, 64479, 64480, 64483, 64484

Medical Policy Group, December 2010 (2)

Medical Policy Administration Committee, January 2011

Available for comment, January 11 through February 21, 2011

Medical Policy Group, June 2011 (2): Clarification of use of ultrasounds with trigger points

Medical Policy Administration Committee, July 2011

Available for comment July 6 through August 22, 2011

Medical Policy Group, December 2011; 2012 Coding Updates: Updated codes 27096, 62310, 62311, and 77003

Medical Policy Group May 2014 (2): Added “dry needling” to clarify that this technique is a type of trigger point injection. Added a coverage statement that intradiscal injections of any substance is investigational. Description, Key Points, Key Words, References updated to reflect changes.

Medical Policy Administration Committee, May 2014

Available for comment May 22 through July 5, 2014

Medical Policy Group, July 2014 (3): added conservative therapy definition to updated policy statement section; Added CPT code 20999 for “dry needling”. Also removed sections related to Sacroiliac Joint Injections which are now located on new policy #558. No other updates.

Medical Policy Administration Committee, August 2014

Available for comment September 8 through October 22, 2014

Medical Policy Group, September 2014 (3): added word “modality(ies)” to description of physical therapy in conservative therapy definition per Medical Director .

Medical Policy Group, August 2015 (2): added clarification statement to policy section regarding multiple epidural injections performed at the same spinal level.

Medical Policy Panel, November 2015

Medical Policy Group, February 2016 (2): 2016 Updates to Description, Key Points, Key Words, Approved by Governing Bodies, and References; added additional criteria to policy section on epidural injections (simultaneous treatment of 2 or more levels and the use of fluorography) and changed the number of injections allowed in 12 months to 6; added clinical vetting section to policy.

Medical Policy Administration Committee, February 2016

Available for comment February 3 through March 18, 2016

Medical Policy Group, March 2016 (2): Updates to Description, Key Points, and References; Facet Injections coverage criteria updated – changed affected level to region (i.e. cervical, thoracic, or lumbosacral*).

Medical Policy Administration Committee, April 2016

Available for comment March 31 through May 15, 2016

Medical Policy Panel, August 2016

Medical Policy Group, August 2016 (7): 2016 Updates to Description, Key Points, Key Words, Approved by Governing Bodies and References. Previous Coding section removed; deleted (codes 64470, 64472, 64475, 64476) effective 2010. No changes to policy statement.

Medical Policy Group, December 2016: 2017 Annual Coding Update.  Created Previous Coding section and moved deleted cpt codes 62310 and 62311 to this section.  Added new cpt codes 62320 – 62323 to Current Coding section.

Medical Policy Group, February 2017 (7): Update to Title; removed all aspects of facet joint injections, now in separate policy, #141.

Medical Policy Group, April 2017 (7): Clarification to “conservative therapy” definition.

Medical Policy Panel, April 2017

Medical Policy Group, May 2017 (7): Updates to Key Points and References. No change to policy statement.

Medical Policy Panel, November 2017

Medical Policy Group, November 2017 (7): Updates to Key Points and References; Removed policy statement from 2014. No change in policy intent.

Medical Policy Panel, April 2018

Medical Policy Group, June 2018 (7): Literature review of Trigger Points and Dry Needling. References updated. No change to policy statement.

Medical Policy Panel, November 2018

Medical Policy Group, December 2018 (7): Literature review of Epidural Injections. Key Points and References updated. No change to policy statement.

Medical Policy Panel, April 2019

Medical Policy Group, May 2019 (7): Literature review of Trigger Point Injections and Dry Needling. Updates to Key Points and References. Removed Previous Coding section, codes 62310 and 62311 deleted 12/31/16. Removed policy statement from 2016. No change in policy intent.

Medical Policy Panel, November 2019

Medical Policy Group, December 2019 (7): Literature review of Epidural Steroid Injections. Updates to Key Points and References.

Medical Policy Group, December 2019: 2020 Annual Coding Update. Added CPT codes 20560, 20561 to the Current coding section. No change in Policy Statement.

Medical Policy Panel, April 2020

Medical Policy Group, May 2020 (7): Literature review of Trigger Point Injections and Dry Needling. Updates to Key Points and References. No change in Policy Statement.

Medical Policy Group, October 2020 (7): 2021 Annual Coding Update. Minor revisions to descriptions of CPT codes: 64479, 64480, 64483, 64484.

Medical Policy Panel, November 2020

Medical Policy Group, December 2020 (7): Literature review of Epidural Steroid Injections. Updates to Key Points and References. No change in Policy Statement.

Medical Policy Group, April 2021 (7): Update to Title; removed all aspects of trigger point injections and dry needling from policy, now in separate policies, #739 Trigger Point Injections and #740 Dry Needling of Trigger Points. Policy section updated to remove “not medically necessary” statement. No change in intent. Added CPT 22899 to Coding Section.

Medical Policy Panel, November 2021

Medical Policy Group, November 2021 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, November 2022

Medical Policy Group, November 2022 (7): Updates to Key Points and References. No change in Policy Statement.

Medical Policy Panel, November 2023

Medical Policy Group, December 2023 (7): Updates to Key Points, Benefit Application, and References. No change in Policy Statement.

Medical Policy Group, October 2024 (7): Clarification to Policy Statement- added note, "Bilateral injections performed on a single level are counted as one injection towards the maximum." No change in policy intent. 

Medical Policy Panel, November 2024

Medical Policy Group, November 2024 (7): Updates to Description and Key Points. No new references added. No change in Policy Statement.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.