Transforaminal epidural injection (64479, 64480, 64483, 64484, 0228T, 0229T, 0230T, 0231T) 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:

• Differentiating Between Diagnoses
  
  
  • Providing assistance in distinguishing between differential diagnoses (e.g., intercostal neuralgia vs. thoracic facet syndrome);
    
    
  • Pain appears to be due to a classic disease of a nerve root (mono-radiculopathy), but the neurodiagnostic studies have failed to provide a structural explanation;
    
    
  • Radiological studies demonstrate an abnormality related to an adjacent nerve root only;
    
    
  • Differentiate between an anatomic variation or a true positive finding of the cause of pain;
    
    
  • The clinical picture is suggestive, but not typical, for both nerve root and distal nerve or joint disease;
    
    
• A discrepancy exists between the demonstrated pathology and the symptoms/complaints or findings (e.g., radiologic evidence of an L4 disc bulge with S1 root syndrome);
  
  
• Multiple sources of pain are present (e.g., there is nerve root dysfunction from mid-lumbar disc disease vs. nerve damage symptoms from an old chronic knee injury);
  
  
• To determine whether the origin of pain is central or peripheral (e.g., leg pain following spinal cord injury);
  
  
• Multiple sclerosis is a covered indication when the purpose of the procedure is an intrathecal Baclofen test dose injection.

Transforaminal epidural injections are appropriate for all of the following therapeutic purposes:

• Radicular pain resistant to, or patient with a contraindication to, other therapeutic means (such as non-narcotic analgesic, physical therapy, etc.), or when surgery is contraindicated;
  
  
• Post-decompressive radiculitis or post-surgical scarring;
  
  
• Monoradicular pain, confirmed by diagnostic blockade, in which a surgically correctable lesion cannot be identified;
  
  
• Treatment of acute herpes zoster or post-herpetic neuralgia;
  
  
• Reflex sympathetic dystrophy or causalgia/complex regional pain syndrome I and II, in lieu of sympathetic block;
  
  
• Acute post-operative pain management following major surgery.

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 every 2 weeks.

Transforaminal epidural injection at the same site should be limited to 4 times per year.

Repeat epidural injections extending beyond 12 months will be reviewed for medical necessity.

Transforaminal epidural injections are considered not medically necessary in the following situations:

• When performed without fluoroscopic or CT guidance;
  
  
• When used for the treatment of low back pain associated with "myofascial pain syndrome," or for the treatment of a soft-tissue source of pain in which no nerve root pathology exists;
  
  
• When performed on the same day as an interlaminar or caudal epidural/intrathecal injection, facet joint or nerve block, sacroiliac joint injection, lumbar sympathetic block, or other nerve block, unless:

1. the anesthetic response to the first injection was assessed and documented to have resulted in incomplete pain relief prior to proceeding with an additional injection; or
   
   
2. the patient has multiples sources of pain, and also requires anticoagulants, but has discontinued the anticoagulant treatment for the pain treatment injections in order to receive multiple block injections on the same day.

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 the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Refer to Medical Policy Bulletin Z-61 for information on Paravertebral Facet Joint Nerve Blocks.

Refer to Medical Policy Bulletin A-10 for information on Pain Control.

Place of Service: Outpatient

Transforaminal epidural injection is typically an outpatient procedure that is eligible for coverage only as an inpatient procedure under special conditions including, but not limited to, current therapeutic anticoagulation therapy.

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).

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

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

Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. 2009 Jan-Feb;12(1):233-51.

Lee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection in lumbosacral herniated disk and spinal stenosis. J Back Musculoskelet Rehabil. 2009;22(2):83-9.

Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: A comprehensive literature review. J Back Musculoskelet Rehabil. 2011 Jan 1;24(2):67-76.

McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011 May;12(5):726-31.

InterQual® Level of Care Criteria 2010. Acute Care Adult. McKesson Health Solutions, LLC.