Chronic pain management is the treatment of a chronic pain condition by a physician described as having duration of greater than six weeks. Chronic pain is also defined as pain that persists past the time of expected tissue healing. This policy is to provide guidelines for determination of medical necessity for such chronic pain management. Medical necessity determinations for chronic pain management will be based on the documented clinical information and/or treatment plan submitted by the physician.

DEFINITIONS:

CONSERVATIVE TREATMENT:  Non- steroidal medications and physical therapy in appropriate cases can be used in interventional therapies as well as injections and blocks.  These methods should be given a chance of success prior to long-term opioid management or surgical intervention.

PAIN: Pain is a sensory and emotional response to tissue damage or potential tissue damage that leads to a reaction.

ACUTE PAIN: Pain with duration of six weeks or less is termed acute.

CHRONIC PAIN: Pain with a duration of greater than six weeks is defined as chronic. Chronic pain is also defined as pain that persists past the time of expected tissue healing.

DISEASE BASED TREATMENT PROGRAM:  Interventional technique applied should match the diagnoses of the patient.

PROCEDURE: LUMBAR EPIDURAL STEROID INTRALAMINAR 

DISEASE: Lumbar radiculitis, spinal stenosis, lumbar herniated nucleus pulposis, lumbar disc disease, foraminal stenosis, post herpetic neuralgia, nerve root injury, post laminectomy syndrome.

FREQUENCY: Three epidurals are allowed in a six month span.

PROCEDURE: LUMBAR/ SACRAL EPIDURAL STEROID TRANSFORAMINAL

DISEASE: Lumbar radiculitis, sacral radiculitis, post herpetic neuralgia, lumbar herniated nucleus pulposus, lumbar disc disease, post laminectomy syndrome.

FREQUENCY: Three transforaminals are allowed in a six month span.

QUALIFIER: The patient should have signs or symptoms suggesting one or more specific nerve root abnormalities. Examples would include loss of reflex, motor deficit, or sensory loss.

PROCEDURE:  EPIDURAL, OF BLOOD OR CLOT PATCH

DISEASE:  Headache following lumbar or spinal puncture.

FREQUENCY:  As needed by medical necessity.

PROCEDURE: CAUDAL EPIDURAL STEROID

DISEASE: Lumbar radiculitis, coccygodynia, spinal stenosis, sacral radiculitis, post herpetic neuralgia, post laminectomy syndrome.

FREQUENCY: Three caudals are allowed in a six month span.

PROCEDURE: THORACIC EPIDURAL

DISEASE: Thoracic radiculitis, thoracic degenerative disc disease, thoracic spinal stenois, thoracic disc herniation, post-herpetic neuralgia, post-thoracotomy syndrome, post-laminectomy syndrome.

FREQUENCY: Three epidurals are allowed in a six month span.

PROCEDURE: THORACIC TRANSFORAMINAL EPIDURAL 

DISEASE: Thoracic radiculitis, intercostal neuralgia, thoracic disc disease, post laminectomy syndrome.

QUALIFIER: The patient should have findings on exam to suggest a specific nerve root or roots are the cause of the pain syndrome.

FREQUENCY: Three epidurals are allowed in a six month period.

PROCEDURE: CERVICAL INTRALAMINAR EPIDURAL

DISEASE: Cervical radiculitis, cervical disc disease, spinal stenosis, post laminectomy syndrome, cervical disc herniation, post-herpetic neuralgia, nerve root injury.

FREQUENCY: Three epidurals are allowed in a six month period.

PROCEDURE: CERVICAL TRANSFORAMINAL EPIDURAL

DISEASE: Cervical radiculitis, spinal stenosis, cervical disc disease, cervical disc herniation, nerve root injury, post-herpetic neuralgia.

QUALIFIER: The patient should have findings on exam to suggest a specific nerve root or nerve roots are the cause of the pain syndrome.

PROCEDURE: LUMBAR FACET JOINT INTRA-ARTICULAR INJECTION

Refer to Medical Policy Bulletin Z-61.

PROCEDURE: LUMBAR FACET JOINT MEDIAN BRANCH BLOCK

DISEASE: See facet joint intra-articular.

FREQUENCY: Three medial branch blocks are allowed in three months.

QUALIFIER: The medial branch block can be used in place of the intra-articular injection, or it may be used as a diagnostic test for radiofrequency ablation. If intra-articular blocks have been performed within the determined time period, median branch blocks should only be done if radiofrequency is being considered.

PROCEDURE: CERVICAL FACET JOINT INTRA-ARTICULAR BLOCK

Refer to Medical Policy Bulletin Z-61.

PROCEDURE: CERVICAL FACET JOINT MEDIAN BRANCH BLOCK

DISEASE: Cervical spondylosis with or without myelopathy, cervical facet joint syndrome, cervical disc disease, cervical spondylolithesis, cervical facet arthropathy.

FREQUENCY: Three medial branch blocks are allowed in three months – no more than five per year.

QUALIFIER: The medial branch block can be used in place of the intra-articular injection, or it may be used as a diagnostic test for radiofrequency ablation. If intra-articular blocks have been performed within the determined time period, median branch blocks should only be done if radiofrequency is being considered.

PROCEDURE: THORACIC FACET JOINT INTRA-ARTICULAR BLOCK

Refer to Medical Policy Bulletin Z-61.

PROCEDURE: THORACIC FACET JOINT MEDIAN BRANCH BLOCK

DISEASE: Thoracic spondylosis with or without myelopathy, thoracic facet joint arthropathy, thoracic facet joint syndrome, traumatic injury to facet, thoracic strain/sprain.

FREQUENCY: Three medial branch blocks are allowed in three months – no more than five per year.

QUALIFIER: The medial branch block can be used in place of the intra-articular injection, or it may be used as a diagnostic test for radiofrequency ablation. If intra-articular blocks have been performed within the determined time period, median branch blocks should only be done if radiofrequency is being considered.

PROCEDURE: SACROILIAC JOINT INJECTION

DISEASE: Sacroiliac joint arthropathy, sacroilitis, tenderness sacroiliac joint.

FREQUENCY: Three injections over six months – no more than five per year.

PROCEDURE: LUMBAR SYMPATHETIC PLEXUS BLOCK

DISEASE: Reflex sympathetic dystrophy, complex regional pain syndrome, ischemic extremity pain, Raynaud’s disease, causalgia of limb, peripheral vasospasm.

FREQUENCY: Six blocks may be performed over three months. In some cases additional blocks may be needed. In the event that additional blocks are requested, the progress made during the blocks should be objectively documented.

PROCEDURE: STELLATE GANGLION BLOCK

DISEASE: Reflex sympathetic dystrophy, complex regional pain syndrome, ischemic extremity pain, Raynaud’s disease, causalgia of limb, peripheral vasospasm, and facial pain syndromes.

FREQUENCY: Six blocks may be performed over three months. In some cases additional blocks may be needed. In the event that additional blocks are requested, the progress made during the blocks should be objectively documented.

PROCEDURE: CELIAC PLEXUS BLOCK

DISEASE: Chronic pancreatitis, acute pancreatitis, abdominal pain of the upper quadrant.

FREQUENCY: Six blocks may be performed over three months. In cancer patients a neurolytic block may be performed if the diagnostic block gives relief of 50% or more.

PROCEDURE: INJECTION OF KNEE 

DISEASE: Osteoarthritis of the knee, knee pain

FREQUENCY: Three injections may be performed over six months – no more than five per year.

PROCEDURE: INJECTION OF THE KNEE:  HYALGEN

DISEASE: Osteoarthritis of the knee, knee pain.

FREQUENCY: Three injections may be performed over six months – no more than five per year.

QUALIFIER: The patient should have good temporary relief from injection of steroid that does not give sustained improvement.

PROCEDURE: INJECTION OF THE SHOULDER

DISEASE: Osteoarthritis of the shoulder, subacromial bursitis, biceps tendonitis.

FREQUENCY: Three injections may be performed over six months – no more than five per year.

PROCEDURE: INJECTION OF THE ELBOW: STRUCTURES

DISEASE: Epicondylitis, bursitis, tendonitis.

FREQUENCY: Three injections over six months – no more than five per year.

PROCEDURE: INJECTION OF THE HIP

DISEASE: Bursitis, osteoarthritis of the hip, hip pain

FREQUENCY: Three injections over six months – no more than five per year.

PROCEDURE: INJECTION OF OTHER INTERMEDIATE JOINTS

DISEASE: Bursitis, arthritis of joint, tendonitis, pain in joint.

FREQUENCY: Three injections over six months - no more than five per year.

PROCEDURE: INJECTION OF SMALL JOINTS

DISEASE: Bursitis, arthritis of joint, tendonitis, pain in joint.

FREQUENCY: Three injections over six months – no more than five per year.

PROCEDURE: INTERCOSTAL NERVE BLOCK

DISEASE: Intercostal neuritis, thoracic radiculitis, costochondritis, traumatic rib fracture.

FREQUENCY: Six injections over six months.

PROCEDURE: ILIOINGUINAL NERVE BLOCK

DISEASE: Ilioinguinal nerve entrapment, neuritis, inguinal hernia, post surgical pain.

FREQUENCY: Six blocks over six months.

PROCEDURE: GENITOFEMORAL NERVE BLOCK

DISEASE: Genitofemoral neuritis, nerve entrapment, post surgical pain.

FREQUENCY: Six blocks over six months.

PROCEDURE: TRIGGER POINT INJECTION

DISEASE: Myofascial pain syndrome, muscle spasm, torticollis, dystonia.

FREQUENCY:  Three injections over six months – no more than five per year.

PROCEDURE: BOTOX OR MYOBLOCK INJECTION

DISEASE: Myofascial pain syndrome, muscle spasm, dystonia, torticollis, spasticity, contracture of muscle or tendon.

FREQUENCY: Three injections over six months.

QUALIFIER: The patient should have a good, but transient response to injection of local anesthetic or local anesthetic with steroid.

PROCEDURE: RADIOFREQUENCY ABLATION OF THE FACET JOINT; LUMBAR, CERVICAL OR THORACIC

DISEASE: Lumbar spinal spondylosis with or without myelopathy, lumbar strain/sprain, lumbar sacral strain/sprain, lumbar facet joint syndrome, lumbar facet joint arthropathy, lumbar spondylolithesis. Cervical spondylosis with or without myelopathy, cervical facet joint syndrome, cervical disc disease, cervical spondylolithesis, cervical facet arthropathy. Thoracic spondylosis with or without myelopathy, thoracic facet joint arthropathy, thoracic facet joint syndrome, traumatic injury to facet, thoracic strain/sprain.

FREQUENCY: One time every six months. May do unilateral on two occasions or one bilateral procedure.  If more than three levels are treated documentation is required. to support medical necessity.

QUALIFIER: Two or three diagnostic blocks should be performed prior to moving forward with the radiofrequency procedure. The blocks ideally should be by the median nerve block technique; however the intra-articular block is acceptable. The temporary subjective and objective improvement should be documented with the diagnostic block.

PROCEDURE: RADIOFREQUENCY ABLATION OF THE SACROILIAC JOINT

DISEASE:   Sacroilitis, disorders of sacrum, ankylosis lumbosacral of SI joint, OA, instability lumbosacral or SI joint.  Radicular pain.

FREQUENCY: One time every six months.  Procedure unilateral; but bilateral appropriate as required by medical condition of patient. If more than three levels are treated documentation required to support medical necessity.  

QUALIFIER:  If favorable response to facet injection after more conservative measures have failed.

PROCEDURE: PULSED RADIOFREQUENCY OF NERVE

Procedure is similar to RF except the PRF waves are delivered at a lower temperature (i.e. to 42 degrees C compare to temperatures in the 60 degree C with continuous RF procedure)

DISEASE:  Lumbar, thoracic or cervical spinal spondylosis with or without myelopathy, lumbar, thoracic or cervical sprain/sprain, facet joint syndrome, or arthropathy,  spondylolithesis

FREQUENCY:  Two or three diagnostic blocks should be performed prior to moving forward with the PRF procedure.  Blocks should ideally be by the medican nerve block technique; however the intra-articular block is acceptable.  The temporary subjective and objective improvement should be documented with the diagnostic block.  If more than three levels are treated documentation is required to show medical necessity.

PROCEDURE: SPINAL CORD STIMULATION

DISEASE:  Intractable pain caused by nerve root injuries, post-surgical or post-traumatic including post-laminectomy syndrome (failed back syndrome), complex regional pain syndrome I and II, causalgia, phantom limb pain, peripheral vascular disease, arachnoiditis lumbosacral, post herpetic neuralgia, plexopathy, cauda equine injury, incomplete spinal cord injury, neuritis or radiculitis. 

FREQUENCY:  As required by failure or malfunction of equipment, intolerance by patient, infection related to device components or loss of effectiveness, migration of lead(s) and justified by the following documentation:

♦SPINAL CORD STIMULATION♦

1. Spinal cord stimulation should be considered when other treatments of extremity, back or neck pain have failed or are not acceptable to the patient,  (i.e. surgical pharmacological, physical, psychologic).
2. Spinal cord stimulation should be considered only after careful physical and psychological screening has been undertaken.  A psychological evaluation should be given, prior to implant, to rule out any untreated psychological problems.
3. Spinal cord stimulation should be performed only facilities with a physician trained in residency or by hands on CME training to perform the procedure.  All technical support, computers and ancillary personnel should be available.
4. A trial spinal cord stimulation lead should be placed prior to permanent implantation.  During the trial period the patient should sustain at least 50% pain relief and objective functional improvement (i.e. range of motion).
5. A documented physiologic problem must exist prior to implementation,  (i.e. physical exam, diagnostic study).
6. No untreated drug addiction problem should exist prior to implementation.
7. The patient should not be implemented if:
   • less than 50% relief is seen with trial stimulation,
   • the patient does not perceive stimulation as pleasant,
   • the patient has an active coagulopathy,
   • the patient has a localized or disseminated infection,
   • the patient has a demand cardiac pacer or may need one relatively soon,
   • the patient has untreated drug addictions,
   • no physiologic problem can be identified,
   • the physician does not have adequate training and experience.
8. A second opinion (when required) should be performed by a physician with credentials to implant like devices.  Second opinions may be performed by chart review.
9. Spinal cord stimulation: The use of new dual lead systems have made  possible the treatment of bilateral extremity pain syndromes such as diabetic   neuropathies.  The use of dual lead stimulators will be approved if the criteria  for single lead systems are met and the pain syndrome is bilateral.  Psychological approval is also required.

PROCEDURE: INTRATHECAL PUMP PLACEMENT

DISEASE:  Chronic pain of malignant origin, chronic severe muscle spasticity due multiple sclerosis, spastic hemiplegia, cerebral palsy, quadriplegia, paraplegia, involuntary muscle spasm and spinal cord injury. Chronic persistent pain secondary to one the following non-malignant causes: Complex regional paid syndrome I and II, causalgia, severe vertebral compression fractures, spinal stenosis, post-herpetic neuralgia, failed back syndrome, (lumbar, thoracic, cervical), phantom limb, arachnoiditis and spinal cord myelopathy.

FREQUENCY:  As required by failure or malfunction of equipment, intolerance by patient, infection related to device components or loss of effectiveness, migration of catheter and justified by the following documentation:

♦TOTALLY IMPLANTABLE INTRATHECAL PUMPS♦

1. These devices are a last resort for chronic intractable pain.
2. Implantable devices may be appropriate if all other surgical, pharmologic, psychologic and physical treatment is contraindicated, has failed or is denied by the patient.
3. A careful trial infusion must be administered for at least 72 hours revealing greater than 50% subjective improvement and some objective improvement (i.e. function).
4. An oral opioid should provide at least partial analgesia prior to implantation.
5. A demonstrated physical cause should be present for pain.
6. A psychology clearance should be obtained prior to implantation ruling out any untreated psychiatric illness.
7. An oral opioid should be unacceptable because of tolerance, side effects or failure to improve function.
8. The intrathecal device should not be considered if:
   • an infection exists locally or intrathecally,
   • an uncontrolled coagulopathy exists,
   • The patient does not do well with the trial infusion,
   • The physician lacks appropriate training.
9. If oral baclofen is helpful, but not giving adequate relief at 80 mg per day, an infusion pump should be considered.
10. A trial intrathecal injection is required.
11. Both subjective and objective improvement should be documented.
12. A second opinion (when required) should be performed by a physician with credentials to implant like devices.  Second opinions may be performed by chart review.

PROCEDURE: TUNNELLED INTRATHECAL OR EPIDURAL CATHETER

DISEASE:  Chronic pain of malignant origin, chronic severe muscle spasticity due to multiple sclerosis, spastic hemiplegia, cerebral palsy, quadriplegia, paraplegia, involuntary muscle spasm and spinal cord injury. Chronic persistent pain secondary to one the following non-malignant causes: Complex regional paid syndrome I and II, causalgia, severe vertebral compression fractures, spinal stenosis, post-herpetic neuralgia, failed back syndrome, (lumbar, thoracic, cervical), phantom limb, arachnoiditis and spinal cord myelopathy.  Extremity pain.

FREQUENCY:  Can be placed short-term (approximately six weeks)  to allow pain control while having rehabilitation to extremities that could not be tolerated otherwise.  As required by failure or malfunction of the catheter.  As justified by medical necessity.

PROCEDURE: SUPRASCAPULAR NERVE BLOCK

DISEASE:  Entrapment of suprascapular nerve caused by different conditions including but not limited to inflammatory diseases and carcinoma etc.  Brachial neuritis or radiculitis.

FREQUENCY:  No more than six blocks over six months.

PROCEDURE: OTHER PERIPHERAL NERVE BLOCK

DISEASE:  Bell's Palsy, carpal tunnel syndrome, diabetic neuropathy, Guillain-Barre Syndrome, sciatica.

FREQUENCY:  No more than six blocks over six months.

PROCEDURE: SUPERIOR HYPOGASTRIC PLEXUS BLOCK

DISEASE:  Chronic pain in pelvic area, either related to nonmalignant or malignant pain. as well as radiation injury.

FREQUENCY:  No more than six in six months.

PROCEDURE: DISCOGRAPHY- LUMBAR

DISEASE:  Intractable chronic back pain.  A disk may be painful when it bulges, herniates, tears or degererates and may cause pain in the low back, abdomen or legs.   Only discography can confirm or deny if the disc itself is the source of pain.

FREQUENCY:  As indicated by medical necessity and supporting documentation.

PROCEDURE: DISCOGRAPHY - CERVICAL OR THORACIC

DISEASE:  Intractable chronic cervical or thoracic pain. A disk may be painful when it bulges, herniates, tears, or degenerates and may cause pain in the neck, mid back, arms or chest wall.  Only discography can confirm or deny if the disc itself is the source of pain.

FREQUENCY:  As indicated by medical necessity and supporting documentation.

PROCEDURE: PERCUTANEOUS ASPIRATION OR DECOMPRESSION OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISK

DISEASE:  Displacement of lumbar intervertebral disc without myelopathy.

FREQUENCY:  One per level.

PROCEDURE: IDET (Intradiscal Electrothermal Annuloplasty Therapy)

DISEASE:   Annular tear.

FREQUENCY:  One per year per level.

PROCEDURE:  SPINAL ENDOSCOPY

DISEASE:  Scar tissue confirmed by MRI or Myelography of cervical, thoracic, or lumbosacral spine.

FREQUENCY:  Once per six months.

PROCEDURE: LYSIS OF ADHESIONS

DISEASE:  Post laminectomy, failed back syndrome, epidural fibrosis with or without adhesive arachnoiditis, scar tissue confirmed by MRI or Myelography of cervical, thoracic or lumbosacral spine

FREQUENCY:  Once per six months as indicated by medical necessity.