Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | S-189 |
Topic: | Transforaminal Epidural Injection |
Effective Date: | July 16, 2007 |
Issued Date: | July 16, 2007 |
Date Last Reviewed: | 03/2007 |
Indications and Limitations of Coverage
Transforaminal epidural injection (64479, 64480, 64483, 64484) is one of many modalities utilized in the management of acute and chronic pain. It has both diagnostic and therapeutic applications. Transforaminal epidural injections are appropriate for all of the following diagnostic situations/purposes:
Transforaminal epidural injections are appropriate for all of the following therapeutic purposes:
Diagnostic transforaminal epidural injection intervals are typically at least 2 weeks. Blockade in cancer pain treatment may be more frequent. The diagnostic phase should be limited to one injection. Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. In the treatment phase, transforaminal epidural injections in the same spinal level are typically administered no more frequently than once very 2 weeks. Transforaminal epidural injection at the same site should be limited to 4 times per year.
Transforaminal epidural injections are considered not medically necessary in the following situations:
When reported for the situations described above, transforaminal epidural injections should be denied as not medically necessary, and therefore, not covered. A participating, preferred, or network provider cannot bill the member for denied service.
Description A transforaminal epidural injection is a neural blockade technique used in chronic pain management. The block can be performed for diagnostic or therapeutic purposes. A selective block is performed of the cervical, thoracic, lumbar, or sacral nerve roots with proximal spread of contrast/local anesthetic through the neural foramen to the epidural space. Fluoroscopic or computed tomography (CT) guidance is used to ensure that the needle tip is placed appropriately within or adjacent to the lateral margin of a neural foramen. Contrast material is injected to verify correct needle placement, determine abnormal filling patterns consistent with foraminal, lateral recess, or nerve root pathology, and to identify unwanted vascular or intrathecal uptake. A small volume of local anesthetic is injected in order to perform a diagnostic, reproducible blockade of a specific nerve root. Therapeutic blocks include a local anesthetic test dose to confirm proper placement (preventing inadvertent arterial injection) followed by injection of anesthetic, antispasmodic, and/or anti-inflammatory substances for the long-term control of pain. The primary diagnostic value of transforaminal epidural injection is to determine the origin of the patient’s pain. The decision to treat chronic pain by invasive or destructive procedures is based on a thorough evaluation of the patient and includes a systematic assessment of the location, intensity, and pathophysiology of the pain. Each injection must be evaluated for clinical efficacy (diagnostically and/or therapeutically). |
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64479 | 64480 | 64483 | 64484 |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review, Pain Physician, Vol. 10(1), Jan 2007 Highmark Medicare Services Medical Policy Bulletin S-155, Transforaminal Epidural Injection, 06/2006 Therapeutic Effect and Outcome Predictors of Sciatica Treated Using Transforaminal Epidural Steroid Injection, American Journal of Roentgenology, Vol. 187(6), Dec 2006 Interlaminar Versus Transforaminal Epidural Injections for the Treatment of Symptomatic Lumbar Intervertebral Disc Herniations, Pain Physician, Vol. 9(4), Oct 2006 Epidural Steroid Therapy for Back and Leg Pain: Mechanisms of Action and Efficacy, Spine Journal, Vol. 5(2), Mar-Apr 2005 Treatment of Lumbar Spinal Stenosis with Epidural Steroid Injections: a Retrospective Outcome Study, Archives of Physical Medicine and Rehabilitation, Vol. 85(3), Mar 2004 |
053.12 |