This version of the policy will become effective on 06/15/2020.
In addition to updates to the description section the following main changes have been made to this policy (please review the updated policy criteria in its entirety as well):
Instead of a maximum of three injection sessions, a maximum of four injection sessions (including diagnostic transforaminal injections) are considered medically necessary and, therefore, covered in each spinal region (cervical or lumbosacral) in a twelve month period.
The following language was removed from the policy criteria section: Epidural injections up to a maximum of three levels per region unilaterally or up to two levels per region bilaterally may be considered for reimbursement.
For paravertebral facet joint blocks policy criteria, thoracic pain is removed. Also, thoracic region is not covered with the exception of C7-T1 and T12-L1. Sacral region is not covered.
In the policy section for REPEAT INJECTIONS FOR TRANSFORAMINAL EPIDURAL INJECTIONS, PARAVERTEBRAL FACET NERVE BLOCKS, AND SACROILIAC JOINT INJECTIONS, pain relief reduction percentage criterion is changed from 50% to 80%.
Note on 06/12/2020 the following revisions were made:
27096, 62320, 62321, 62322, 62323, 64451, 64461, 64462, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 77003, 77012
NOT MEDICALLY NECESSARY
0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T