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:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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
Policy: 00.01.25ay:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Policy: 00.03.02aa:Diagnostic Radiology Services Included in Capitation
Policy: 08.00.57n:Treatments for Complex Regional Pain Syndrome (CRPS)
Policy: 11.15.09n:Denervation of the Spinal Nerves for Chronic Pain
Policy: 11.15.15g:Percutaneous Discectomy