Medical Treatment Guidelines

Treatment Guidelines
Advanced Imaging
Guidelines
Spinal Injections

Coverage decision

Therapeutic medial branch nerve block injections, facet joint injection, and intradiscal injections are not covered services. These injections may be covered diagnostically on a very limited basis.

Therapeutic/diagnostic epidural injections and sacroiliac joint injections are covered services for State Fund, Self-Insured and Crime Victims claims, when the following criteria are met:

The patient has an allowed spine condition, and one of the following:

Radicular pain (pain radiating down the leg or arm)
Radiculopathy, with documented objective findings such as:

Motor weakness.
Dermatomal sensory loss.
Reflex asymmetry or loss.
A positive diagnostic selective nerve root block, which is: single-level, low-volume, steroid-free, includes a post block pain diary and possible placebo injection in the series.

Sacroiliac joint pain.

Epidural injections in the cervical, thoracic or lumbar spine:

Patient’s baseline level of function and pain must be clearly documented.
Patient must have an allowed spine condition.
The allowed condition must be consistent with a finding of radicular pain or radiculopathy.
If only radicular pain is present, there must be a failure of at least 6 weeks of conservative therapy.
When objective evidence of radiculopathy is document, there must be a failure of at least 2 weeks of conservative therapy.
Injection may be with anesthetic agent and/or steroid agent.
Fluoroscopic, CT or ultrasound guidance must be utilized.
Restrictions:

No more than 2 injections (2 dates of service) can be given without documented improvement in function and pain of at least 30%; compared to the baseline documented before the commencement of injections. Function and pain must be measured and documented on a validated instrument.
No more than 3 injections within 6 months.
No more than 2 levels and one side per date of service.
MRI is not a prerequisite for performance of ESI.

Sacroiliac joint injections

Patient has an allowed condition that includes sacroiliac joint pain
Failure of at least 6 weeks of conservative therapy
Must be done with fluoroscopic or CT guidance
Restrictions:

No more than 1 injection without documented improvement in function and pain of at least 30%, compared to the baseline documented before the commencement of injections. Requests for more than 2 injections requires clinical review.

Facet injections and medial branch blocks

These injections are used on a diagnostic basis only to determine whether the patient is a candidate for a facet neurotomy

There must be failure of at least 6 months of conservative therapy.
Patient must have the clinical findings and diagnostic tests outlined in the facet neurotomy guideline.
Reference the facet neurotomy guideline, before planning a facet injection or medial branch block.
Restrictions: see facet neurotomy guideline for details.

Note: CPT codes are the same regardless of the purpose of these injections; only diagnostic are covered.

Intradiscal injections

Not covered for the assessment of chronic low back pain or lumbar degenerative disc disease; for other conditions, see coverage decision on discography.

An example of a validated scale that measures function and pain:

Standard Questions: Pain interference and intensity
In the last month, how much has pain interfered with your daily activities? Use a scale from 0 to 10, where 0 is “no interference” and 10 is “unable to carry on any activities.”
No interference						Unable to carry on any activities
0	1	2	3	4	5	6	7	8	9	10
In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0 is “no pain” and 10 is “pain as bad as it could be.” (That is, your usual pain at times you were in pain)
No pain						Pain as bad as it could be
0	1	2	3	4	5	6	7	8	9	10

The following are NOT included in this coverage decision:

Sympathetic blocks.
Trigger point injections.
Dry needling.
Hyaluronic acid injections.
Adhesiolysis.
Intraarticular injections.
Botulinum toxins.
Occipital nerve root blocks.

Background policy information

On March 18, 2011, the State Health Technology Clinical Committee (HTCC) met at an open public meeting to determine whether state agencies should pay for spinal injections. Based on a review of the best available evidence of safety, efficacy and cost-effectiveness, the committee decided to cover spinal injections with certain limitations. The decision was made final by the HTCC on June 17, 2011.

Complete information on this HTCC determination is available at: http://www.hta.hca.wa.gov.

All requests for spinal injections require prior authorization

How to request authorization for spinal injections:

L&I (State fund):

Request Utilization Review provided by Qualis.

For Crime Victims

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact the Crime Victims’ Compensation Program’s Claim Manager by:

Phone: 800-762-3716 (toll free).
Fax: 360-902-5333.

Additional information is available at: www.CrimeVictims.Lni.wa.gov.

For Self-Insured Claims:

Contact the employer.

Billing and payment information

Providers should add the prior authorization number to their bill.

Codes	Injection Type	Therapeutic	Diagnostic
62310 64483 62311 64484 62318 0228T 62319 0229T 64479 0230T 64480 0231T	Epidural Injections Cervical, Thoracic or Lumbar	Covered, with conditions and utilization review	Covered, with conditions and utilization review
27096	Sacroiliac Joint Injections	Covered, with conditions and utilization review	Not covered
64490 0213T 64491 0214T 64492 0215T 64493 0216T 64494 0217T 64495 0218T	Facet Injections Medial Branch Blocks	Not covered Not covered	Covered with conditions; Candidates for facet neurotomy
N/A	Intradiscal	Not covered	Not covered

Definitions

Conservative therapy: Conservative therapy includes evidence-based treatments that have been demonstrated to be of use in the management of low back or neck pain; such as physical therapy or graded exercise, massage, medications, etc.

For a reference on conservative treatment of low back pain, see:
Chou R, Quaseem A, Snow V, Casey D, Cross TJ, Shekelle P and Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine 2007; 147:478-491.

Measuring clinically meaningful improvement: While there is no universally accepted tool to assess a worker’s function and pain, the Washington State Agency Medical Directors’ Group (AMDG), in its opioid dosing guideline, recommends the use of the Two-Item Graded Chronic Pain Scale (below). This is a quick, two-question tool to track both function and pain when administered regularly during a patient’s treatment. Other functional assessment tools that are well validated and disease-specific may also be used to assess the worker’s physical functioning. If a disease-specific tool is used, each tool will have its own definition for clinically meaningful improvement. Examples of meaningful improvement include resumption of physical activities and activities of daily living, improved work capacity, and/or the ability to progress in vocational retraining.

For more information:
Teresa Cooper, RN, ONC
360-902-5762
Teresa.Cooper@lni.wa.gov

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