Interventional Pain Management

Transcription

1 Interventinal Pain Management Guidelines Musculskeletal Prgram Interventinal Pain Management EFFECTIVE NOVEMBER 1, 2017 LAST REVIEWED JUNE 13, 2017 Apprpriate.Safe.Affrdable 2017 AIM Specialty Health v.1

2 Table f Cntents Descriptin and Applicatin f the Guidelines... 3 Epidural Injectin Prcedures and Diagnstic Selective Nerve Rt Blcks... 4 Descriptin... 4 Definitins... 4 Criteria... 5 Exclusins... 7 Selected References... 7 CPT Cdes... 8 Paravertebral Facet Injectin/Nerve Blck/Neurlysis... 9 Descriptin... 9 Definitins... 9 Criteria Exclusins Selected References CPT Cdes Reginal Sympathetic Nerve Blck Descriptin Definitins Criteria Exclusins Selected References CPT Cdes Sacriliac Jint Injectin Descriptin Definitins Criteria Exclusins Selected References CPT Cdes Spinal Crd Stimulatrs fr Permanent Implantatin Descriptin Definitins Criteria Selected References CPT Cdes Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 2

3 Descriptin and Applicatin f the Guidelines AIM s Clinical Apprpriateness Guidelines (hereinafter AIM s Clinical Apprpriateness Guidelines r the Guidelines ) are designed t assist prviders in making the mst apprpriate treatment decisin fr a specific clinical cnditin fr an individual. As used by AIM, the Guidelines establish bjective and evidence-based, where pssible, criteria fr medical necessity determinatins. In the prcess, multiple functins are accmplished: T establish criteria fr when services are medically necessary T assist the practitiner as an educatinal tl T encurage standardizatin f medical practice patterns T curtail the perfrmance f inapprpriate and/r duplicate services T advcate fr patient safety cncerns T enhance the quality f healthcare T prmte the mst efficient and cst-effective use f services AIM s guideline develpment prcess cmplies with applicable accreditatin standards, including the requirement that the Guidelines be develped with invlvement frm apprpriate prviders with current clinical expertise relevant t the Guidelines under review and be based n the mst up t date clinical principles and best practices. Relevant citatins are included in the References sectin attached t each Guideline. AIM reviews all f its Guidelines at least annually. AIM makes its Guidelines publicly available n its website twenty-fur hurs a day, seven days a week. Cpies f the AIM s Clinical Apprpriateness Guidelines are als available upn ral r written request. Althugh the Guidelines are publicly-available, AIM cnsiders the Guidelines t be imprtant, prprietary infrmatin f AIM, which cannt be sld, assigned, leased, licensed, reprduced r distributed withut the written cnsent f AIM. AIM applies bjective and evidence-based criteria and takes individual circumstances and the lcal delivery system int accunt when determining the medical apprpriateness f health care services. The AIM Guidelines are just guidelines fr the prvisin f specialty health services. These criteria are designed t guide bth prviders and reviewers t the mst apprpriate services based n a patient s unique circumstances. In all cases, clinical judgment cnsistent with the standards f gd medical practice shuld be used when applying the Guidelines. Guideline determinatins are made based n the infrmatin prvided at the time f the request. It is expected that medical necessity decisins may change as new infrmatin is prvided r based n unique aspects f the patient s cnditin. The treating clinician has final authrity and respnsibility fr treatment decisins regarding the care f the patient and fr justifying and demnstrating the existence f medical necessity fr the requested service. The Guidelines are nt a substitute fr the experience and judgment f a physician r ther health care prfessinals. Any clinician seeking t apply r cnsult the Guidelines is expected t use independent medical judgment in the cntext f individual clinical circumstances t determine any patient s care r treatment. The Guidelines d nt address cverage, benefit r ther plan specific issues. If requested by a health plan, AIM will review requests based n health plan medical plicy/guidelines in lieu f the AIM s Guidelines. The Guidelines may als be used by the health plan r by AIM fr purpses f prvider educatin, r t review the medical necessity f services by any prvider wh has been ntified f the need fr medical necessity review, due t billing practices r claims that are nt cnsistent with ther prviders in terms f frequency r sme ther manner. CPT (Current Prcedural Terminlgy) is a registered trademark f the American Medical Assciatin (AMA). CPT five digit cdes, nmenclature and ther data are cpyright by the American Medical Assciatin. All Rights Reserved. AMA des nt directly r indirectly practice medicine r dispense medical services. AMA assumes n liability fr the data cntained herein r nt cntained herein. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 3

4 Epidural Injectin Prcedures and Diagnstic Selective Nerve Rt Blcks Descriptin Epidural sterid injectin (ESI) invlves the administratin f crticsterid via insertin f a needle int the epidural space surrunding the spinal nerve rt. Despite the lack f cnsistent evidence t supprt its efficacy, the prcedure is widely used in patients with chrnic back, neck and radicular pain. In 2014, the US Fd and Drug Administratin issued a drug safety cmmunicatin abut epidural injectin f gluccrticids, citing the risk fr rare but serius adverse effects (lss f visin, strke, paralysis, and death). The best evidence supprting its use cmes frm trials that lked specifically at patients with radiculpathy due t disc herniatin, where shrt term benefit has been demnstrated. Injectins may be perfrmed as part f a diagnstic wrkup f radicular pain, r as a therapeutic mdality when nninvasive treatment strategies have failed. Injectins may be perfrmed via an interlaminar apprach, transframinal apprach, r caudal apprach (thrugh the sacral hiatus at the sacral canal). Selective nerve rt blck is a related prcedure that utilizes a small amunt f anesthetic, injected via transframinal apprach, t anesthetize a specific spinal nerve. Diagnstic selective nerve rt blcks are used t evaluate a patient s anatmical level and/r surce f radicular pain and are ften used in surgical planning and decisin making. Definitins Cnservative management shuld include a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral, r addictin disrders Dcumentatin f cmpliance with a plan f therapy that includes elements frm these areas is required. Exceptins may be cnsidered n a case-by-case basis. Reprting f symptm severity Severity f pain and its impact n activities f daily living (ADLs) is a key factr in determining the need fr interventin. Fr purpses f this guideline, significant pain and functinal impairment refers t pain that is at least 3 ut f 10 in intensity and is assciated with inability t perfrm at least tw (2) ADLs. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 4

5 Imaging studies All imaging must be perfrmed and read by an independent radilgist. If discrepancies shuld arise in the interpretatin f the imaging, the radilgist reprt will supersede. The results f all imaging studies shuld crrelate with the clinical findings in supprt f the requested prcedure. Criteria Therapeutic Epidural Sterid Injectin (ESI) f the cervical r lumbar spine may be indicated when all f the fllwing criteria are met: Radicular pain (cervical r lumbar) r neurgenic claudicatin (lumbar) with assciated functinal impairment Evidence f nerve rt cmpressin r spinal stensis (central r framinal) is seen n an advanced imaging study (MRI r CT) and crrelates with the clinical findings* The pain has nt respnded t at least fur (4) weeks f apprpriate cnservative management, unless there is evidence f radiculpathy, in which case ESI may be perfrmed fllwing tw (2) weeks f cnservative management. *NOTE: The initial epidural injectin fr a given episde f pain in the lumbar spine may be perfrmed withut cnfirmatry advanced imaging if the exam findings are clearly diagnstic f nerve rt cmpressin r spinal stensis. Repeat Therapeutic ESI may be indicated when all f the fllwing criteria are met: The prir injectin prduced at least a 50% reductin in pain with functinal imprvement f at least three (3) weeks duratin** The patient has a recurrence f pain with significant functinal disability The patient cntinues t participate in a cnservative treatment between injectins **NOTE: If the initial injectin did nt result in pain relief, repeat injectin may be indicated, prvided that the injectin is perfrmed at an adjacent level, OR at the same level utilizing a different apprach r type f sterid. Diagnstic Selective Nerve Rt Blck (DSNRB), als knwn as diagnstic transframinal injectin, is defined as the injectin f anesthetic nly, fr the purpse f determining the need fr surgical interventin. DSNRB may be indicated in the evaluatin and diagnstic wrk-up f radicular pain fllwing cnsultatin with a spine surgen in any f the fllwing scenaris: T cnfirm nerve rt cmpressin r spinal stensis (central r framinal) nted n an advanced imaging study (MRI r CT) and that is cnsistent with, and appears t be cntributing t, the patient s symptms. T determine r cnfirm the (r mst) symptmatic level (i.e., site f cmpressin) in the presence f multi-level invlvement fr which the primary symptmatic level is unclear. When radiculpathy is highly suspected but cannt be cnfirmed with advanced imaging studies. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 5

6 Prcedural Requirements and Restrictins: Injectins must be perfrmed under flurscpy r CT guidance. A maximum f three (3) injectins (including diagnstic transframinal injectins) may be perfrmed in each spinal regin (cervical r lumbsacral) in a six (6) mnth perid. N mre than tw (2) transframinal injectins may be perfrmed at a single setting (e.g., single level bilaterally r tw levels). Injecting ne level bilaterally wuld be cnsidered tw injectins. Injecting tw levels, each unilaterally, wuld als be cnsidered tw injectins. Fr caudal r cervical/lumbar interlaminar injectins, nly ne injectin per sessin may be perfrmed and NOT in cnjunctin with a transframinal injectin. A sessin is defined as all ESIs r spinal prcedures perfrmed n a single day. After three injectins in the same regin, the ttal cumulative dse f sterid must be dcumented and may nt exceed 240 mg f methylprednislne r triamcinlne r 36 mg f betamethasne r 45 mg f dexamethasne. Cntraindicatins and Risks The fllwing cnditins shuld prmpt further evaluatin prir t cnsidering ESI: New nset f lw back pain r neck pain in the setting f established malignancy, r where there is a suspicin f malignancy based n the clinical presentatin New nset f lw back pain r neck pain in persns with risk factrs fr spinal infectin Cmrbid cnditins assciated with increased risk f bleeding due t cagulpathy r treatment with anticagulants Back pain in the setting f trauma Additinal cntraindicatins include the fllwing cnditins: Cauda equina syndrme Cnus medullaris syndrme Epidural hematma Subarachnid hemrrhage Epidural mass Spinal crd ischemia Spinal fracture which ccurred less than 6 weeks prir t injectin Demyelinating disease r ther CNS prcesses which predispse t transverse myelitis Systemic infectin Lcal infectin at the injectin site Uncntrlled diabetes Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 6

7 Exclusins Indicatins ther than thse addressed in this guideline are cnsidered nt medically necessary, including but nt limited t the fllwing: Thracic level ESI perfrmed fr thracic pathlgy Mderate t severe myelpathy n clinical exam Myelpathy assciated with intramedullary crd signal change n T1 r T2 weighted MRI Islated axial neck pain r lw back pain Selected References 1 Ammendlia CS, K. J.; Rk, E.; Rampersaud, R.; Kennedy, C. A.; Pennick, V.; Steenstra, I. A.; de Bruin, L. K.; Furlan, A. D. Nnperative treatment fr lumbar spinal stensis with neurgenic claudicatin. Cchrane Database Syst Rev. 2013(8):CD Bicket MC, Hrwitz JM, Benzn HT, et al. Epidural injectins in preventin f surgery fr spinal pain: systematic review and meta-analysis f randmized cntrlled trials. The spine jurnal : fficial jurnal f the Nrth American Spine Sciety. 2015;15(2): Chu R, Leser JD, Owens DK, et al. Interventinal therapies, surgery, and interdisciplinary rehabilitatin fr lw back pain: an evidence-based clinical practice guideline frm the American Pain Sciety. Spine. 2009;34(10): Chen SPH, S.; Semenv, Y et al.. Epidural sterid injectins, cnservative treatment, r cmbinatin treatment fr cervical radicular pain: a multicenter, randmized, cmparative-effectiveness study. Anesthesilgy. 2014;121(5): COST B13 Wrking Grup n Guidelines fr Chrnic Lw Back Pain, Airaksinen O, Brx JI, et al. Chapter 4. Eurpean guidelines fr the management f chrnic nnspecific lw back pain. Eur Spine J. 2006;15 Suppl 2:S COST B13 Wrking Grup n Guidelines fr Chrnic Lw Back Pain, van Tulder M, Becker A, et al. Chapter 3. Eurpean guidelines fr the management f acute nnspecific lw back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S Falc FJ, Manchikanti L, Datta S, et al. Systematic review f the therapeutic effectiveness f cervical facet jint interventins: an update. Pain physician. 2012;15(6):E Institute fr Clinical Systems Imprvement GM, Thrsn D, et al.. Adult acute and subacute lw back pain. 2012:92 pgs.. 9 Institute f Health Ecnmics. Tward Optimized Practice. Guideline fr the evidence-infrmed primary care management f lw back pain. 2011: Kaye ADM, L.; Abdi, S.; et al.. Efficacy f Epidural Injectins in Managing Chrnic Spinal Pain: A Best Evidence Synthesis. Pain physician. 2015;18(6):E Kreiner DS, Hwang, S. W., Nrth American Spine, Sciety, et al. An evidence-based clinical guideline fr the diagnsis and treatment f lumbar disc herniatin with radiculpathy. Spine J. 2014;14(1): Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline fr the diagnsis and treatment f degenerative lumbar spinal stensis (update). The spine jurnal : fficial jurnal f the Nrth American Spine Sciety. 2013;13(7): Lee CHL, J.; Kang, J. D. et al.. Laminplasty versus laminectmy and fusin fr multilevel cervical myelpathy: a meta-analysis f clinical and radilgical utcmes. J Neursurg Spine. 2015;22(6): Lewis RAW, N. H.; Suttn, A. J., et al.. Cmparative clinical effectiveness f management strategies fr sciatica: systematic review and netwrk meta-analyses. Spine J. 2015;15(6): Liu KL, P.; Liu, R.; Wu, X.; Cai, M. Sterid fr epidural injectin in spinal stensis: a systematic review and meta-analysis. Drug Des Devel Ther. 2015;9: MacVicar JK, W.; Landers, M. H.; Bgduk, N. The effectiveness f lumbar transframinal injectin f sterids: a cmprehensive review with systematic analysis f the published data. Pain Medicine. 2013;14(1): Manchikanti LB, R. M.; Falc, F. J.; Kaye, A. D.; Hirsch, J. A. D Epidural Injectins Prvide Shrt- and Lng-term Relief fr Lumbar Disc Herniatin? A Systematic Review. Clin Orthp. 2015;473(6): Manchikanti LN, D. E.; Candid, K. D., et al.. D cervical epidural injectins prvide lng-term relief in neck and upper extremity pain? A systematic review. Pain physician. 2015;18(1): Meng HF, Q.; Wang, B.; Yang, Y.; Li, D.; Li, J.; Su, N. Epidural injectins with r withut sterids in managing chrnic lw back pain secndary t lumbar spinal stensis: a meta-analysis f 13 randmized cntrlled trials. Drug Des Devel Ther. 2015;9: Natinal Institute fr Health and Care Excellence,Lw back pain and sciatica in ver 16s: assessment and management,(2016),lndn UK, 21 Nrth American Spine Sciety,Lumbar Epidural Injectins - NASS Cverage Plicy Recmmendatins,(May 2014),Burr Ridge IL,12 pgs. 22 Nrth American Spine Sciety,Cervical Epidural Infectins - NASS Cverage Plicy Recmmendatins,(May 2014),Burr Ridge IL 10 pgs. 23 Phillips FMS, P. J.; Yussef, J. A.; Anderssn, G.; Papathefanis, F. Lumbar spine fusin fr chrnic lw back pain due t degenerative disc disease: a systematic review. Spine. 2013;38(7):E Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 7

8 24 Pint RZM, C. G.; Ferreira, M. L., et al. Epidural crticsterid injectins in the management f sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12): Radcliff KK, C.; Hilibrand, A., et al.. Epidural sterid injectins are assciated with less imprvement in patients with lumbar spinal stensis: a subgrup analysis f the Spine Patient Outcmes Research Trial. Spine. 2013;38(4): Rathmell JP, Benzn HT, Dreyfuss P, et al. Safeguards t Prevent Neurlgic Cmplicatins after Epidural Sterid InjectinsCnsensus Opinins frm a Multidisciplinary Wrking Grup and Natinal Organizatins. Anesthesilgy. 2015;122(5): Zhang YL, C.; Ta, Y., et al. Cervical ttal disc replacement is superir t anterir cervical decmpressin and fusin: a meta-analysis f prspective randmized cntrlled trials. PLS ONE. 2015;10(3):e CPT Cdes Injectin(s), f diagnstic r therapeutic substance(s) (eg, anesthetic, antispasmdic, piid, sterid, ther slutin), nt including neurlytic substances, including needle r catheter placement, interlaminar epidural r subarachnid, cervical r thracic; withut imaging guidance Injectin(s), f diagnstic r therapeutic substance(s) (eg, anesthetic, antispasmdic, piid, sterid, ther slutin), nt including neurlytic substances, including needle r catheter placement, interlaminar epidural r subarachnid, cervical r thracic; with imaging guidance (ie, flurscpy r CT) Injectin(s), f diagnstic r therapeutic substance(s) (eg, anesthetic, antispasmdic, piid, sterid, ther slutin), nt including neurlytic substances, including needle r catheter placement, interlaminar epidural r subarachnid, lumbar r sacral (caudal); withut imaging guidance Injectin(s), f diagnstic r therapeutic substance(s) (eg, anesthetic, antispasmdic, piid, sterid, ther slutin), nt including neurlytic substances, including needle r catheter placement, interlaminar epidural r subarachnid, lumbar r sacral (caudal); with imaging guidance (ie, flurscpy r CT) Injectin(s), anesthetic agent and/r sterid, transframinal epidural, with imaging guidance (flurscpy r CT); cervical r thracic, single level Injectin(s), anesthetic agent and/r sterid, transframinal epidural, with imaging guidance (flurscpy r CT); cervical r thracic, each additinal level (List separately in additin t cde fr primary prcedure) Injectin(s), anesthetic agent and/r sterid, transframinal epidural, with imaging guidance (flurscpy r CT); lumbar r sacral, single level Injectin(s), anesthetic agent and/r sterid, transframinal epidural, with imaging guidance (flurscpy r CT); lumbar r sacral, each additinal level (List separately in additin t cde fr primary prcedure) Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 8

9 Paravertebral Facet Injectin/Nerve Blck/Neurlysis Descriptin Paravertebral facet jints, als referred t as zygapphyseal jints r Z-jints, have been implicated as a surce f chrnic neck and lw back pain with a prevalence f up t 70% in the cervical spine, and up t 30% in the lumbar spine. Neither physical exam nr imaging has adequate diagnstic pwer t cnfidently identify the facet jint as a pain surce. Facet jint injectin techniques have evlved primarily as a diagnstic tl fr pain riginating in these jints, but have been widely utilized t treat chrnic pain shwn t be f facet rigin. Injectins may be perfrmed at ne f tw sites, either the jint itself (intraarticular injectin) r the nerve that supplies it (medial branch f the drsal ramus f segmental spinal nerves). Diagnstic injectins are perfrmed with an anesthetic agent alne, while therapeutic injectins invlve administratin f a crticsterid, with r withut an anesthetic. Fllwing cnfirmatin f facet pathlgy using a diagnstic medial branch blck (MBB), select patients may underg a radifrequency nerve ablatin prcedure. Studies have validated the efficacy f this interventin in chrnic pain f facet rigin. Definitins Cnservative management shuld include a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral, r addictin disrders Dcumentatin f cmpliance with a plan f therapy that includes elements frm these areas is required. Exceptins may be cnsidered n a case-by-case basis. Reprting f symptm severity Severity f pain and its impact n activities f daily living (ADLs) is a key factr in determining the need fr interventin. Fr purpses f this guideline, significant pain and functinal impairment refers t pain that is at least 3 ut f 10 in intensity, and is assciated with inability t perfrm at least tw (2) ADLs. Imaging studies All imaging must be perfrmed and read by an independent radilgist. If discrepancies shuld arise in the interpretatin f the imaging, the radilgist reprt will supersede. The results f all imaging studies shuld crrelate with the clinical findings in supprt f the requested prcedure. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 9

10 Criteria Prcedures must be perfrmed with image guidance, either flurscpy r CT Patients must meet all f the fllwing criteria: Mderate t severe pain with functinal impairment f at least three (3) mnths duratin Predminant axial pain that is nt attributable t radiculpathy**, myelpathy, r neurgenic claudicatin Physical exam findings which are cnsistent with the facet jint as the presumed surce f pain Absence f nn-facet pathlgy that culd explain the surce f the patient s pain, such as fracture, tumr, r infectin. Absence f prir surgical fusin at the prpsed level Lack f imprvement r reslutin fllwing at least six (6) weeks f cnservative management **With the exceptin f synvial cysts Diagnstic Medial Branch Blcks (MBB) The primary utility f MBBs is t determine the suitability f the patient fr a radifrequency neurtmy f painful segmental levels in rder t achieve lng-term pain management. A psitive respnse is defined as at least 80% relief f the primary (index) pain, with the nset and duratin f relief being cnsistent with the agent emplyed. Nte: The patient must be experiencing pain at the time f the injectin (generally rated at least 3 ut f 10 in intensity) in rder t determine whether a respnse has ccurred. Prvcative maneuvers r psitins which nrmally exacerbate index pain shuld als be assessed and dcumented befre and after the prcedure. Dual MBBs, defined as injectins perfrmed in the same lcatin(s) n tw (2) separate ccasins at least ne week apart, are necessary t cnfirm the diagnsis due t the unacceptably high false psitive rate f single MBB injectins. A cnfirmatry injectin is indicated nly if the first injectin results in a psitive respnse. If the secnd injectin als results in a psitive respnse, the target jint(s) is/are the cnfirmed pain generatr(s). If the first sessin f diagnstic MBBs are negative, a maximum f ne additinal sessin may be perfrmed t determine the primary levels f invlvement prir t prceeding with cnfirmatry blcks. A maximum f tw (2) levels may be injected during a single sessin. Therapeutic Intraarticular (IA) Facet Jint Injectins Therapeutic IA injectins shuld be repeated n mre than three times annually and nly if the initial injectin results in significant pain relief (at least 50%) fr at least three (3) mnths. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 10

11 Thermal Medial Branch Radifrequency Neurtmy (RFN) RFN may be ffered t patients if dual diagnstic MBB injectins each prduce 80% relief f the primary (index) pain and the nset and minimum duratin f relief is cnsistent with the agent emplyed. RFN may be perfrmed at the same level n mre than twice annually and nly if the initial radifrequency lesin results in significant pain relief (at least 50%) and imprvement in patient specific ADLs fr at least six (6) mnths. Fr each cvered spinal regin (cervical r lumbar), RFN shuld be perfrmed at n mre than fur (4) jints per sessin (e.g., tw [2] bilateral levels r fur [4] unilateral levels). Repeat RFN t treat recurrent facet jint pain in a patient wh has failed ther cnservative measures may be cvered withut repeating diagnstic MBB injectins if the patient has experienced significant and prlnged relief f pain (at least 50% reductin fr at least five [5] mnths) and imprvement f functin in the past fllwing RF ablatin. RFN may nt be perfrmed at C0-C1 r at C1-C2 Prcedural Limitatins (MBB, IA) A maximum f six (6) facet jint prcedural sessins per regin (cervical r lumbar) may be perfrmed in a 12-mnth perid, regardless f type r indicatin. One additinal diagnstic blck may be indicated prir t a repeat neurtmy when there is diagnstic uncertainty abut the surce f pain. Exclusins Indicatins ther than thse addressed in this guideline are cnsidered nt medically necessary, including but nt limited t the fllwing: Diagnstic intraarticular facet jint injectin Therapeutic medial branch blck Diagnstic r therapeutic IA injectin, medial branch blck, r radifrequency ablatin in the thracic regin with the exceptin f C7-T1 and T12-L1 Use f MBB r RFN in the setting f mderate t severe spndyllisthesis (grade 2 r higher) Use f MBB r RFN in the setting f an islated pars defect Use f MBB r RFN at the level f a psterlateral fusin r psterir instrumentatin Use f nn-thermal RF mdalities fr facet jint denervatin, including chemical, lw grade thermal energy (<80 degrees Celsius), and pulsed RF Any facet jint interventins perfrmed under ultrasund guidance Intraarticular r extra-articular facet jint prltherapy Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 11

12 Selected References 1 Bswell MV, Manchikanti L, Kaye AD, et al. A Best-Evidence Systematic Appraisal f the Diagnstic Accuracy and Utility f Facet (Zygapphysial) Jint Injectins in Chrnic Spinal Pain. Pain physician. 2015;18(4):E Centers fr Medicare and Medicaid Services, Lcal Cverage Determinatins: Facet Jint Injectins, Medial Branch Blcks, and Facet Jint Radifrequency Neurtmy, (2016) Baltimre MD, 62 pgs. 3 Chu R, Leser JD, Owens DK, et al. Interventinal therapies, surgery, and interdisciplinary rehabilitatin fr lw back pain: an evidence-based clinical practice guideline frm the American Pain Sciety. Spine. 2009;34(10): COST B13 Wrking Grup n Guidelines fr Chrnic Lw Back Pain, Airaksinen O, Brx JI, et al. Chapter 4. Eurpean guidelines fr the management f chrnic nnspecific lw back pain. Eur Spine J. 2006;15 Suppl 2:S Falc FJ, Manchikanti L, Datta S, et al. Systematic review f the therapeutic effectiveness f cervical facet jint interventins: an update. Pain physician. 2012;15(6):E Lee CHL, J.; Kang, J. D. et al.. Laminplasty versus laminectmy and fusin fr multilevel cervical myelpathy: a meta-analysis f clinical and radilgical utcmes. J Neursurg Spine. 2015;22(6): Manchikanti L, Abdi S, Atluri S, et al. An update f cmprehensive evidence-based guidelines fr interventinal techniques in chrnic spinal pain. Part II: guidance and recmmendatins. Pain physician. 2013;16(2 Suppl):S Manchikanti LB, R. M.; Falc, F. J.; Kaye, A. D.; Hirsch, J. A. D Epidural Injectins Prvide Shrt- and Lng-term Relief fr Lumbar Disc Herniatin? A Systematic Review. Clin Orthp. 2015;473(6): Nrth American Spine Sciety, Facet Jint Interventins - NASS Cverage Plicy Recmmendatins, (August 2016) Burr Ridge IL, 16 pgs. CPT Cdes Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphysial) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), cervical r thracic; single level Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphysial) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), cervical r thracic; secnd level (List separately in additin t cde fr primary prcedure) Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), cervical r thracic; third and any additinal level(s) (List separately in additin t cde fr primary prcedure) Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), lumbar r sacral; single level Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), lumbar r sacral; secnd level (List separately in additin t cde fr primary prcedure) Injectin(s), diagnstic r therapeutic agent, paravertebral facet (zygapphyseal) jint (r nerves innervating that jint) with image guidance (flurscpy r CT), lumbar r sacral; third and any additinal level(s) (List separately in additin t cde fr primary prcedure) Destructin by neurlytic agent, paravertebral facet jint nerve(s), with imaging guidance (flurscpy r CT); cervical r thracic, single facet jint Destructin by neurlytic agent, paravertebral facet jint nerve(s), with imaging guidance (flurscpy r CT); cervical r thracic, each additinal facet jint (List separately in additin t cde fr primary prcedure) Destructin by neurlytic agent, paravertebral facet jint nerve(s), with imaging guidance (flurscpy r CT); lumbar r sacral, single facet jint Destructin by neurlytic agent, paravertebral facet jint nerve(s), with imaging guidance (flurscpy r CT); lumbar r sacral, each additinal facet jint (List separately in additin t cde fr primary prcedure) Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 12

13 Reginal Sympathetic Nerve Blck Descriptin Sympathetic blckade includes prcedures that temprarily bstruct the lcal functin f the sympathetic nervus system. Anesthetic is injected directly int sympathetic neural structures that serve affected limb(s), such as the stellate ganglin r the lumbar sympathetic chain. Radilgic guidance (flurscpy r CT scan) is utilized t ensure accuracy. Reginal sympathetic nerve blck has been utilized primarily fr treatment f cmplex reginal pain syndrme. Despite limited evidence supprting its efficacy, it has als been investigated in treating a number f ther pain syndrmes thught t be sympathetically mediated. This and ther interventinal prcedures shuld be cnsidered nly when the full spectrum f nninvasive management strategies has nt prvided sufficient relief f symptms. Definitins Cnservative management shuld include a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral r addictin disrders Dcumentatin f cmpliance with a plan f therapy that includes elements frm these areas is required. Exceptins may be cnsidered n a case-by-case basis. Reprting f symptm severity -- Severity f pain and its impact n activities f daily living (ADLs) is a key factr in determining the need fr interventin. Fr purpses f this guideline, significant pain and functinal impairment refers t pain that is at least 3 ut f 10 in intensity, and is assciated with inability t perfrm at least tw (2) ADLs. Imaging studies -- All imaging must be perfrmed and read by an independent radilgist. If discrepancies shuld arise in the interpretatin f the imaging, the radilgist reprt will supersede. The results f all imaging studies shuld crrelate with the clinical findings in supprt f the requested prcedure. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 13

14 Criteria Cmplex Reginal Pain Syndrme (Type I r Type II) Diagnstic criteria fr Cmplex Reginal Pain Syndrme (CRPS) must be met: Cntinuing pain that is disprprtinate t any inciting event At least 1 symptm reprted in at least three (3) f the fllwing categries: Sensry: Hyperesthesia r alldynia Vasmtr: Temperature asymmetry, skin clr changes, skin clr asymmetry Sudmtr/edema: Edema, sweating changes, r sweating asymmetry Mtr/trphic: Decreased range f mtin, mtr dysfunctin (eg, weakness, tremr, dystnia), r trphic changes (eg, hair, nail, skin) At least 1 sign at time f evaluatin in at least tw (2) f the fllwing categries: Sensry: Evidence f hyperalgesia (t pinprick), alldynia (t light tuch, temperature sensatin, deep smatic pressure, r jint mvement) Vasmtr: Evidence f temperature asymmetry (>1 C), skin clr changes r asymmetry Sudmtr/edema: Evidence f edema, sweating changes, r sweating asymmetry Mtr/trphic: Evidence f decreased range f mtin, mtr dysfunctin (eg, weakness, tremr, dystnia), r trphic changes (eg, hair, nail, skin) N ther diagnsis better explaining the signs and symptms In additin, all f the fllwing are required: Level f pain and disability in the mderate t severe range Failure f at least tw (2) weeks f cnservative management Dcumentatin f nging participatin in a cmprehensive pain management prgram The perfrmance f an initial diagnstic reginal sympathetic blck is cnsidered medically necessary t establish the presence r absence f sympathetically mediated cmplex reginal pain syndrme. A psitive respnse is defined as a significant reductin in pain (at least 80% reductin) and imprvement in functin with the duratin f relief being cnsistent with agent emplyed, and bjective evidence that the blck was physilgically effective. Fr prcedures that target pain in a limb, there must be dcumentatin f a rise in temperature frm baseline f the ipsilateral limb. A sensry exam is required t cnfirm absence f spread t adjacent nerve rts. Fllwing a psitive respnse t the initial diagnstic blck,additinal diagnstic and therapeutic reginal sympathetic blcks, up t maximum f six (6) ttal blcks, perfrmed at a frequency f n mre than tw (2) per week, may be cnsidered medically necessary when all the fllwing criteria have been met: Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 14

15 Benefit has been demnstrated by prir blcks as evidenced by all f the fllwing: Decreased use f pain medicatin Imprved level f functin (e.g., increased range f mtin, strength, and use f extremity in activities f daily living) Imprved tlerance t tuch (e.g., decreased alldynia) r ther bjective measures The interventin is being prvided as part f a cmprehensive pain management prgram (physical therapy, patient educatin, psychscial supprt, and ral medicatin). If there is n sustained benefit in pain and functin after three (3) sympathetic blcks frm baseline (pre blck) pain and functin, then additinal blcks are nt warranted. If there is sustained benefit after the first three (3) sympathetic blcks then up t three (3) additinal blcks may be perfrmed. Exclusins Indicatins ther than thse addressed in this guideline are cnsidered nt medically necessary, including but nt limited t the fllwing: Use f intravenus phentlamine (Regitine) as a diagnstic test fr CRPS Intravenus reginal sympathetic blck utilizing guanethidine Intrapleural analgesia fr treatment f CRPS Selected References 1. Harden RN, Oaklander AL, Burtn AW, Perez RS, Richardsn K, Swan M, Barthel J, Csta B, Gracisa JR, Bruehl S; Reflex Sympathetic Dystrphy Syndrme Assciatin. Cmplex reginal pain syndrme: practical diagnstic and treatment guidelines, 4th editin. Pain Med Feb;14(2): di: /pme Epub 2013 Jan O'Cnnell NEW, B. M.; Gibsn, W., et al.. Lcal anaesthetic sympathetic blckade fr cmplex reginal pain syndrme. Cchrane Database Syst Rev. 2016;7:CD Zernikw BW, J.; Brehmer, H.; Hirschfeld, G.; Maier, C. Invasive treatments fr cmplex reginal pain syndrme in children and adlescents: a scping review. Anesthesilgy. 2015;122(3): CPT Cdes Injectin, anesthetic agent; stellate ganglin (cervical sympathetic) Injectin, anesthetic agent; lumbar r thracic (paravertebral sympathetic) Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 15

16 Sacriliac Jint Injectin Descriptin Nn-inflammatry sacriliac (SI) jint cmplex pain may be traumatic, degenerative, r due t adjacent segment disease (after lumbar fusin r ttal hip replacement). Sacriliitis is assciated with inflammatry spndylarthrpathies. Pain arising frm the SI jint cmplex typically radiates t the gluteal area and psterir hip. In additin t lcalized tenderness ver the SI jint, there are additinal examinatin maneuvers which suggest the diagnsis. Definitins Cnservative management shuld include a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral, r addictin disrders Dcumentatin f cmpliance with a plan f therapy that includes elements frm these areas is required. Exceptins may be cnsidered n a case-by-case basis. Reprting f symptm severity -- Severity f pain and its impact n activities f daily living (ADLs) is a key factr in determining the need fr interventin. Fr purpses f this guideline, significant pain and functinal impairment refers t pain that is at least 3 ut f 10 in intensity, and is assciated with inability t perfrm at least tw (2) ADLs. Imaging studies -- All imaging must be perfrmed and read by an independent radilgist. If discrepancies shuld arise in the interpretatin f the imaging, the radilgist reprt will supersede. The results f all imaging studies shuld crrelate with the clinical findings in supprt f the requested prcedure. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 16

17 Criteria Prcedures must be perfrmed with image guidance, either flurscpy r CT Patients must meet all f the fllwing inclusin criteria t be able t prceed with diagnstic intraarticular SI jint injectins, therapeutic intraarticular SI jint injectins, r diagnstic lateral branch blcks. There is persistent typically unilateral nn-radicular pain that is predminantly belw the lumbar spine (L5) and is primarily lcalized ver the regin f the sacriliac jint and has been present fr at least three (3) mnths. Examinatin shws lcalized tenderness with palpatin ver the sacral sulcus just inferir t the psterir superir iliac spine (PSIS) in the absence f tenderness f equal severity elsewhere (e.g., lumbar spine, greater trchanter, hip, cccyx) At least ne f the fllwing prvcative tests is psitive: pelvic distractin test, lateral iliac cmpressin test, sacral cmpressin/thrust test, thigh thrust test, FABER (Patrick s test), and Gaenslen s test. There is n evidence f acute r subacute radicular pain/radiculpathy r neurgenic claudicatin. If there is evidence f radicular pain/radiculpathy r neurgenic claudicatin the cnditin must be fixed and stable and have been maximally addressed thrugh cmprehensive treatment. Lack f adequate imprvement fllwing six (6) weeks f cnservative management. Diagnstic Intraarticular Sacriliac Jint Injectins The primary utility f diagnstic intraarticular sacriliac jint injectins is t determine if the sacriliac jint is the primary pain generatr fr the patient s lw back pain. Dual intraarticular sacriliac jint injectins, defined as injectins perfrmed in the same jint n 2 separate ccasins, are necessary t cnfirm the diagnsis due t the unacceptably high false psitive rate f single intraarticular sacriliac jint injectins. A secnd cnfirmatry injectin is indicated nly if the first injectins prduces greater than r equal t 80% relief f the primary (index) pain and the nset and minimum duratin f relief is cnsistent with the agent emplyed. This cnfirmatry blck cnfirms the tested sacriliac jint as the surce if the index pain is reduced by greater than r equal t 80% and the nset and minimum duratin f relief is cnsistent with the agent emplyed. Anesthetic vlume must be limited t 1.5 cc t maximize the anatmic specificity f the prcedure. Cncurrent injectin f sterid is nt apprpriate fr diagnstic SI jint injectin. The day f the prcedure, the patient s pain must be at least 3/10 severity at rest r during a cnsistently prvcative maneuver, which will allw accurate mnitring f the respnse t the injectin. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 17

18 Therapeutic Intraarticular (IA) Sacriliac Jint Injectins Therapeutic IA sacriliac jint injectins are perfrmed with the use f crticsterid with r withut the use f anesthetic. Ttal injectin vlume shuld be limited t 2.0 cc t minimize extravasatin f the injectate utside f the SI jint. Repeat Therapeutic Intraarticular Sacriliac Jint Injectins Repeat injectin is cnsidered medically necessary if symptms recur and the patient has demnstrated at least 50% pain relief, and imprvement in patient-specific ADLs, fr at least 6 weeks after a previus injectin. Injectins may nt be repeated at intervals f less than three (3) mnths, with a maximum f three (3) injectins in a 12 mnth perid. Treatment with therapeutic injectins shuld be accmpanied by participatin in an nging active rehabilitatin prgram, hme exercise prgram, r functinal restratin prgram. Ultrasund-guidance Exclusins Ultrasund is the nly imaging-guidance apprpriate fr use during pregnancy Indicatins ther than thse addressed in this guideline are cnsidered nt medically necessary, including but nt limited t the fllwing: Intraarticular sacriliac jint injectins perfrmed n the same day as ther spine injectin prcedures. Use f crticsterid with diagnstic intraarticular sacriliac jint injectins Selected References 1 Chu R, Leser JD, Owens DK, et al. Interventinal therapies, surgery, and interdisciplinary rehabilitatin fr lw back pain: an evidence-based clinical practice guideline frm the American Pain Sciety. Spine. 2009;34(10): COST B13 Wrking Grup n Guidelines fr Chrnic Lw Back Pain, Airaksinen O, Brx JI, et al. Chapter 4. Eurpean guidelines fr the management f chrnic nnspecific lw back pain. Eur Spine J. 2006;15 Suppl 2:S Hansen H, Manchikanti L, Simpuls TT, et al. A systematic evaluatin f the therapeutic effectiveness f sacriliac jint interventins. Pain physician. 2012;15(3):E Manchikanti L, Abdi S, Atluri S, et al. An update f cmprehensive evidence-based guidelines fr interventinal techniques in chrnic spinal pain. Part II: guidance and recmmendatins. Pain physician. 2013;16(2 Suppl):S Muheremu AN, X.; Wu, Z.; et al.. Cmparisn f the shrt- and lng-term treatment effect f cervical disk replacement and anterir cervical disk fusin: a meta-analysis. Eur. 2015;25 Suppl 1:S Nrth American Spine Sciety,Sacriliac Jint Injectins - NASS Cverage Plicy Recmmendatins, (2015),Burr Ridge IL, 11 pgs. 7 Zaidi HAM, A. J.; Dickman, C. A. Surgical and clinical efficacy f sacriliac jint fusin: a systematic review f the literature. J Neursurg Spine. 2015;23(1): CPT Cdes Injectin prcedure fr sacriliac jint, anesthetic/sterid, with image guidance (flurscpy r CT) including arthrgraphy when perfrmed Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 18

19 Spinal Crd Stimulatrs fr Permanent Implantatin Descriptin Spinal crd stimulatrs, als knwn as drsal clumn stimulatrs, are implantable devices used t treat chrnic pain. Electrdes are surgically placed within the dura mater via laminectmy, r by percutaneus insertin int the epidural space. Lw vltage electrical signals are delivered t the drsal clumn f the spinal crd in rder t verride r mask sensatins f pain. The patient s pain distributin pattern determines the level at which the stimulatin lead is placed. The lead may incrprate fur (4) t eight (8) electrdes, with 8 electrdes typically used fr cmplex pain patterns, such as bilateral pain r pain extending frm the limbs t the trunk. Implantatin is typically a 2-step prcess. Initially, the electrde is temprarily implanted in the epidural space, allwing a trial perid f stimulatin. Once treatment effectiveness is cnfirmed (defined as at least 50% reductin in pain), the electrdes and radi receiver/ transducer are permanently implanted. Extensive prgramming f the neurstimulatrs is ften required t achieve ptimal pain cntrl. Definitins Cnservative management shuld include a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral, r addictin disrders Dcumentatin f cmpliance with a plan f therapy that includes elements frm these areas is required. Exceptins may be cnsidered n a case-by-case basis. Reprting f symptm severity -- Severity f pain and its impact n activities f daily living (ADLs) is a key factr in determining the need fr interventin. Fr purpses f this guideline, significant pain and functinal impairment refers t pain that is at least 3 ut f 10 in intensity, and is assciated with inability t perfrm at least tw (2) ADLs. Imaging studies -- All imaging must be perfrmed and read by an independent radilgist. If discrepancies shuld arise in the interpretatin f the imaging, the radilgist reprt will supersede. Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 19

20 The results f all imaging studies shuld crrelate with the clinical findings in supprt f the requested prcedure. Criteria All f the fllwing criteria are required: Severe pain and disability with dcumented pathlgy r an bjective basis fr the pain. Drsal clumn stimulatin is being used as a late r last resrt after dcumented failure f at least six (6) cnsecutive mnths f physician-supervised cnservative management. Dcumentatin f pain reductin and functinal imprvement fllwing at least a three (3) day trial f percutaneus spinal stimulatin. This shuld include at least a 50% reductin f target pain r analgesic medicatin use, and specific evidence f imprved functin. There is n evidence f existing untreated drug addictin. The patient has been evaluated by a pain management specialist prir t implantatin. All the facilities, equipment, and prfessinal and supprt persnnel required fr the prper diagnsis, treatment training, and fllw-up f the patient must be available. At least ne surgical pinin has been btained t ensure that the patient des nt have a surgically crrectable lesin. Dcumentatin f an evaluatin by a mental health prvider (e.g., a face-t-face assessment with r withut psychlgical questinnaires and/r psychlgical testing) that cnfirms n evidence f an inadequately cntrlled mental health prblem (e.g., alchl r drug dependence, depressin, psychsis) that wuld negatively impact the success f a spinal crd stimulatr r cntraindicate its placement. Drsal clumn stimulatin may be indicated fr the relief f chrnic intractable neurpathic pain f the trunk and/r limbs in the fllwing cnditins: Lumbsacral arachniditis as dcumented by high levels f prtein in the cerebrspinal fluid and/r imaging (MRI r myelgraphy) Nerve rt injuries that are pst-surgical r pst-traumatic, including pst-laminectmy syndrme (failed back syndrme) Cmplex reginal pain syndrme (CRPS), type I r type II (frmerly knwn as reflex sympathetic dystrphy r causalgia) Selected References 1 Centers fr Medicare and Medicaid Services, Natinal Cverage Determinatin fr Electrical Nerve Stimulatrs, (1995) Baltimre MD, 3 pgs. 2 Chu R, Leser JD, Owens DK, et al. Interventinal therapies, surgery, and interdisciplinary rehabilitatin fr lw back pain: an evidence-based clinical practice guideline frm the American Pain Sciety. Spine. 2009;34(10): COST B13 Wrking Grup n Guidelines fr Chrnic Lw Back Pain, Airaksinen O, Brx JI, et al. Chapter 4. Eurpean guidelines fr the management f chrnic nnspecific lw back pain. Eur Spine J. 2006;15 Suppl 2:S Lewis RAW, N. H.; Suttn, A. J., et al.. Cmparative clinical effectiveness f management strategies fr sciatica: systematic review and netwrk meta-analyses. Spine J. 2015;15(6): Manchikanti L, Abdi S, Atluri S, et al. An update f cmprehensive evidence-based guidelines fr interventinal techniques in chrnic spinal pain. Part II: guidance and recmmendatins. Pain physician. 2013;16(2 Suppl):S Cpyright AIM Specialty Health. All Rights Reserved. Interventinal Pain Management 20