IEHP UM Subcommittee Approved Authorization Guidelines Spinal Cord Procedure

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1 Policy: IEHP UM Subcommittee Approved Authorization Guidelines IEHP considers any of the following injections or procedures medically necessary for the treatment of back pain, Prior to initiating spine / spinal cord procedures, it is required that conservative medical treatment will have been tried and documented to have failed. This includes at least the use of medications (anti-inflammatory, muscle relaxants, and other analgesic medications topical and oral) for a minimum of 6 months; and physical therapy for at least 6 weeks and within the prior 6 month period, which targets the area under consideration for injections. Other examples of conservative treatment include the following: rest, heat/ice, modification of activities, bracing, home exercise programs or other treatment modalities as covered by the health plan). ONLY ONE invasive diagnostic or treatment modality or procedure will be considered medically necessary per treatment or diagnostic period. A treatment or diagnostic period will be defined as the community accepted standard length of time expected to produce the desired clinical effect. As an example, once a physician selects a procedure, it should be given sufficient time to produce a meaningful response (the relief or significant improvement) of symptoms; or to rule-in or rule-out a diagnosis. If a therapeutic procedure is shown to be effective at producing significant improvement in the patient s pain, other modalities should NOT be requested. For example, requesting Facet Joint Injections and Epidural (laminar or transforaminal) together in the same or separate spinal region(s) is unacceptable during the same treatment period. Although multiple injection procedures may be necessary for the proper evaluation and management of chronic pain in a given patient; it is expected that good medical practice will be used to determine the type of evaluation that will likely establish the diagnosis or treat the cause. IEHP considers providing a combination of other types of spinal cord injections; such as epidural blocks, facet joint blocks, bilateral sacroiliac joint injections, trigger point injections, lumbar sympathetic blocks, or providing more than two levels of facet joint blocks to a patient on the same day or treatment period) as not reasonable and / or not medically necessary, per the evidence-based medical literature. Such therapy can lead to an improper diagnosis or unnecessary treatment. The provider may proceed to the next logical test or treatment if desired; ONLY WHEN the first diagnostic or treatment procedure fails to produce the desired effect or to rule-out the diagnosis Sixth St, Suite 120, Rancho Cucamonga, CA Tel (909) Fax (909) Visit our web site at: A Public Entity

2 Page 2 of 11 It is expected that the basic workup and conservative treatment of chronic pain patients will be completed prior to initiating or continuing spinal cord procedures. Specifically, when there is radicular pain, or a change in the patient s condition(s), the appropriate documentation of physical findings should be consistent with the objective findings as evidenced by detailed neurologic examination (i.e. sensory and / or motor deficits, and / or abnormal deep tendon reflexes should show specific nerve root levels that are being affected). Also, diagnostic studies such as x-rays, MRI, CT Scans, Nerve-Muscle studies, etc, should be done in order to rule-out other non-spinal causes (tumors, infections, occult fractures, etc); and / or to rule-in nerve involvement before moving forward with the appropriate spinal cord procedures. 1. Facet Joint Injections: a facet joint injection (median branch nerve block) is one of the methods used to diagnose posterior biomechanical (joint) pain of the back which typically does not have a strong radicular component; and when there is no associated neurologic deficit. Pain is characterized during physical exam and diagnostic findings as an aggravation by hyperextension of the spine, by standing and walking, positive facet loading test etc. Indications: a. Used to diagnose chronic pain (pain that has been present for at least six months or more) and characterized predominantly by facet joint pain. b. X-rays showing facet arthropathy can aid in the diagnosis of facet mediated pain. c. Facet joint injections (Medial Branch Blocks) can be considered when patients have failed conservative medical treatment as described above. d. A thorough history and detailed physical exam should be documented to emphasize the type, severity, exacerbating factors including position; in addition, medical as well as psychological disorders should be documented. If the patient fails traditional aggressive analgesic therapy, or the etiology of the pain is uncertain, nerve blocks may play a pivotal role in aiding the diagnosis of FACET JOINT PAIN. Limitations/exclusions also refer to the preceding paragraph: a. Facet Joint Injections are NOT considered proven as a means of on-going therapeutic treatment; but as a diagnostic tool to aid in the diagnosis of facet pain. b. If radiculopathy is suspected other non-spinal causes (such as tumors, infections, occult fractures, etc) should be ruled out by MRI (imaging). If the MRI is negative for evidence of a condition likely to be causing nerve root impingement, such as herniated disc(s), neuroforaminal stenosis, central canal stenosis etc, AND radiculopathy is still suspected, THEN, electrodiagnostic testing, i.e. a nerve conduction study / electromyelographic (NCS/EMG) study should be done to further evaluate and rule-in or rule-out associated nerve root involvement. c. Once radiculopathy has been ruled-out as the source of pain, then A MAXIMUM OF TWO SETS OF FACET JOINT INJECTIONS (one diagnostic set and one confirmatory set can be considered).

3 Page 3 of 11 d. The specific location (RIGHT vs. LEFT vs. BILATERAL) AND specific vertebral levels thought to be affected should be documented by a complete and detailed physical examination. e. Only one region (cervical, thoracic, or lumbar) of the spine should be injected per diagnostic period. the provider may proceed to FACET INJECTIONS IN ANOTHER SPINAL REGION (e.g. starting in the lumbar region, then moving on to the cervical region), only after FACET JOINT INJECTIONS of a region currently under evaluation has been completed. f. A set of injections will be defined as injections done at one or at most two vertebral levels either unilaterally or bilaterally (totaling between one to at most, four injections, in the specified region). g. If pain is considered to be of bilateral origin in a spinal region, it is expected that the physician will document that the condition exists at the initial physical evaluation. If documentation is presented upon subsequent office visits showing that a new location is involved, it will be considered a change in condition. Consideration of initiating treatment with injection procedures in the new area will need to fulfill the conservative treatment recommendations as mentioned above. h. Facet injections should be completed in a logical and sequential manner: When bilateral pain is present, testing (the diagnostic set followed by confirmatory set of injections) is expected to be completed on both sides before proceeding to the next mode of diagnostic or treatment procedures. i. TWO SETS (the diagnostic and confirmatory sets) may be approved in advance on a prior authorization request. Separate sets of injections should not be done any sooner than one week apart from each other (either bilaterally or unilaterally). Documentation should be submitted (i.e. procedure reports, diagnostic reports, detailed physical exam findings, etc) describing the patient s response to BOTH of the FACET INJECTION sets upon submitting additional referral requests to proceed to the next logical diagnostic or treatment mode. j. When a patient is being considered as a candidate for percutaneous radiofrequency ablation(s) / lesioning (RFA / RFL); patient s will be expected to have shown a significant response (documented by relief of pain by a minimum of 50%) to the 2 nd set of facet joint injections; and for a minimum of 6 weeks. k. Once RFA/RFL has been completed on the pertinent facet level(s) in a region, no additional Facet Joint Injections are considered necessary. 2. Trigger point injections of corticosteroids and/or local anesthetics, are considered medically necessary for treating members with chronic neck or back pain or myofascial pain syndrome, when all of the following selection criteria are met: a. Conservative therapies such as bed rest, exercises, heating or cooling modalities, massage, and pharmacotherapies such as non-steroidal anti-inflammatory drugs, muscle relaxants, non-narcotic analgesics, should have been tried and failed, and b. Symptoms have persisted for more than 3 months, and c. Trigger points have been identified by palpation; and

4 Page 4 of 11 d. Trigger point injections are not administered in isolation, but are provided as part of a comprehensive pain management program, including physical therapy, patient education, psychosocial support, and oral medication where appropriate. Trigger point injections are considered experimental and investigational for all other indications. A trigger point is defined as a specific point or area where, if stimulated by touch or pressure, a painful response will be induced. A set of trigger point injections means injections in several trigger points in one sitting. It is not considered medically necessary to repeat injections more frequently than every 7 days. Up to four sets of injections are considered medically necessary to diagnose the origin of a patient's pain and achieve a therapeutic effect; additional sets of trigger point injections are not considered medically necessary if no clinical response is achieved. Once a diagnosis is established and a therapeutic effect is achieved, it is rarely considered medically necessary to repeat trigger point injections more frequently than once every two months. Repeated injections extending beyond 12 months may be reviewed for continued medical necessity. 3. Sacroiliac (SI) joint injections are considered medically necessary to relieve pain associated with lower lumbosacral disturbances in members who meet all of the following criteria: a. Member has moderate-severe, non-radicular low back pain for more than 3 months which is specifically demonstrated to be due to SI joint dysfunction. Demonstration of SI joint dysfunction shall include the following: i. A clinical history which is consistent with SI joint dysfunction. ii. Physical exam findings which are consistent with SI joint dysfunction and must include positive results from at least three (3) of the following clinical tests documented in the medical record: 1. Fortin Finger Test: in which the patient points to the area of pain with one finger. The result is positive if the site of pain is within 1 cm of the posterior superior iliac spine (PSIS), generally inferomedially. 2. Gaenslen Test: in which the patient is tested in the supine position. The hip and knee are maximally flexed toward the trunk, and the opposite leg is extended. Pressure is applied to the flexed extremity. The finding is positive if pain is felt across the SI joint. 3. Patrick s Test (or FABER maneuver): in which the hip is placed into flexion, abduction, and external rotation. The patient lies supine. The heel of the tested side is placed on the opposite knee. Pressure is applied on the flexed knee and the opposite anterior superior iliac spine area. Result is positive for SI joint dysfunction if pain is elicited in the SI joint area. 4. Gillet s Test (One-Legged Stork Test): in which the patient is tested in the standing position. The patient stands on one leg while flexing the opposite hip and knee into the chest. Motion of the SI joint is assessed by placing one thumb under the PSIS on the side of hip flexion, with the other thumb in the midline at the S2 level. Normally, the thumb under the PSIS drops inferiorly and laterally

5 Page 5 of 11 with hip flexion. Restriction is indicated by decreased motion compared to the normal side. 5. Seated Flexion Test: The patient is seated with the examiner behind him. The examiner s thumbs are placed just below the PSIS. The patient flexes the trunk forward. A positive result is obtained if asymmetry of motion is detected. 6. Standing Flexion Test: The patient is standing with the examiner behind him. The examiner s thumbs are placed just below each posterior iliac spine. The patient flexes the trunk forward without bending the knees. A positive result is obtained if asymmetry of motion is detected. iii. Imaging studies of the SI joint are not considered to be useful in the diagnosis of SI joint dysfunction. However, imaging studies of the lumbar spine (such as CT/MRI) are useful in the detection of spinal pathology which is potentially causing referred pain to the SI joints. b. Diagnostic evaluation must first address and rule out other possible pain generators. For example, referred pain to the SI joints from lumbar facet disease, herniated lumbar discs, central canal or neural foraminal narrowing in the lumbar spine, space occupying lesions or infections of the lumbar spine, or lumbar spine trauma, should first be ruled out with imaging studies (CT/MRI) and or EMG/NCS. c. Member has failed conservative treatment including: i. At least 6 months of medications (which may include anti-inflammatories, muscle relaxants, anti-epileptic drugs, anti-depressants, corticosteroids, opioids if necessary, and other analgesic medications both topical and oral) ii. At least 6 weeks of physical therapy within the prior 6 month period which specifically targets the sacroiliac joints being considered for injections. d. SI joint injections are given under fluoroscopic guidance. e. An initial diagnostic injection into the SI joint must result in at least 70% relief from baseline pain in order to proceed to a second, confirmatory SI joint injection in the same joint. These injections should not be performed sooner than 7 days apart. f. Additional SI joint injections beyond the initial two are not considered medically necessary unless at least 50% pain relief is obtained for at least 6 weeks. g. If at least 50% pain relief is achieved for at least 6 weeks following two injections into the SI joint, additional (therapeutic) injections may be performed up to a maximum number of 4 injections per year (12-month period),. These injections should not be performed more frequently than once every 2 months. In addition, to be medically necessary, a therapeutic SI joint injection should not be done unless the previous injection at the same site resulted in at least 50% pain relief for at least 6 weeks. h. An SI joint injection should NOT be performed on the same day as a lumbar translaminar epidural steroid injection (ESI), transforaminal ESI,facet joint injection, or medial branch block.

6 Page 6 of 11 i. SI joint injections are not used in isolation, but are provided as part of a comprehensive pain management program, including physical therapy, patient education, psychosocial support, and oral medication, where appropriate. j. Repeat SI joint injections extending beyond 12 months may be reviewed for continued medical necessity. k. When SI joint injections are performed in excess of established parameters, they may be subject to review for medical necessity. Sacroiliac joint injections are considered experimental and investigational for all other indications. 4. Epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, are considered medically necessary in the outpatient setting for management of persons with radiculopathy or sciatica when all of the following are met: a. Intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out as the cause of pain; and b. Member has failed to improve after 2 or more weeks of conservative measures (e.g., rest, systemic analgesics and/or physical therapy); and c. Epidural injections beyond the first set of 3 injections are provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate. Epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications. Repeat epidural injections beyond the first set of three injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate. Repeat epidural injections more frequently than every 7 days are not considered medically necessary. Up to three epidural injections are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect; if the member experiences no pain relief after three epidural injections, additional epidural injections are not considered medically necessary. Once a therapeutic effect is achieved, it is rarely medically necessary to repeat epidural injections more frequently than once every two months. In selected cases where more definitive therapies (e.g., surgery) cannot be tolerated or provided, additional epidural injections may be considered medically necessary. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity. Experimental and Investigational Interventions: IEHP considers any of the following injections or procedures experimental and investigational: Coccygeal ganglion (ganglion impar) block for pelvic pain; Dynamic stabilization (e.g., Dynesys Spinal System, Graf ligamentoplasty/graf artificial ligament, and the Stabilimax NZ Dynamic Spine Stabilization System);

7 Page 7 of 11 Endoscopic laser foraminoplasty, foraminotomy and laminotomy; Epidural injections of lytic agents (e.g., hyaluronidase, hypertonic saline) or mechanical lysis in the treatment of adhesive arachnoiditis, epidural fibrosis, failed back syndrome, or other indications; Epiduroscopy (also known as epidural myeloscopy, epidural spinal endoscopy, myeloscopy, and spinal endoscopy) for the diagnosis and treatment of intractable LBP or other indications; Facet chemodenervation/chemical facet neurolysis; Facet joint implantation; Far lateral microendoscopic diskectomy (FLMED) for extra-foraminal lumbar disc herniations or other indications; Inter-spinous distraction (e.g., the Coflex inter-spinous stabilization spinal implant, Eclipse inter-spinous distraction device, ExtenSure bone allograft inter-spinous spacer, X-Stop device, and the TOPS System) for spinal stenosis or other indications; Laser facet denervation; Microendoscopic discectomy (MED) procedure for decompression of lumbar spine stenosis, lumbar disc herniation, or other indications; Microsurgical anterior foraminotomy for cervical spondylotic myelopathy or other indications; Minimally invasive/endoscopic cervical laminoforaminotomy for cervical radiculopathy/lateral and foraminal cervical disc herniations or other indications; Minimally invasive lumbar decompression (MILD) procedure for lumbar canal stenosis or other indications; Minimally invasive transforaminal lumbar interbody fusion (MITLIF) for lumbar disc degeneration and instability or other indications; NuFix facet fusion; Percutaneous endoscopic diskectomy with or without laser (PELD) (also known as arthroscopic microdiskectomy or Yeung Endoscopic Spinal Surgery System [Y.E.S.S.]); Piriformis muscle resection; Racz procedure (epidural adhesiolysis with the Racz catheter) for the treatment of members with adhesive arachnoiditis, epidural adhesions, failed back syndrome from multiple previous surgeries for herniated lumbar disk, or other indications; Radiofrequency denervation for sacroiliac joint pain; Radiofrequency lesioning of dorsal root ganglia for back pain; Radiofrequency lesioning of terminal (peripheral) nerve endings for back pain; Sacroiliac fusion or pinning for the treatment of LBP due to sacroiliac joint syndrome; Note: Sacroiliac fusion may be medically necessary for sacroiliac pain due to severe traumatic injury, where a trial of an external fixator is successful in providing pain relief; Sacroplasty for osteoporotic sacral insufficiency fractures and other indications; TruFuse facet fusion; Vesselplasty (e.g., Vessel-X);

8 Page 8 of 11 Xclose Tissue Repair System. Related Coverage Determinations: CMS Local Coverage Determination For Paravertebral Facet Joint Block And Facet Joint Denervation (L28288): If the patient gets sufficient relief of pain from a facet joint block for a meaningful period of time but the pain recurs, one of the options is to denervate the facet joint. This procedure requires placement of a needle in the facet joint under fluoroscopic or CT guidance, injection of a local anesthetic agent, and if the pain is relieved (confirming that the needle is in the area desired to be denervated), injection of a neurolytic agent to destroy the facet joint nerve. This denervation can also be achieved by passing an electric current through a similarly placed electrode, by applying heat or by using radiofrequency. When facet joint block has been effective in managing the back pain under consideration, then a permanent denervation may be considered, but should be restricted only to the level or levels that, from the results of the blocks, can be reasonably considered the source of the pain. This may not include all the levels that were blocked. Special Considerations Regarding CPT Code 77003: According to The American Medical Association s Current Procedural Terminology Professional Edition 2013 and the National Correct Coding Initiative Edits adopted by Medi-Cal in March 2011, the following CPT codes regarding spinal injection procedures may not be billed together with CPT code (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid): 27096: Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. This procedure includes confirmation of intra-articular needle placement with CT or fluoroscopy : Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical, thoracic, lumbar or sacral. Imaging guidance (fluoroscopy or CT) and any contrast injection are included in these codes : Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical, thoracic, lumbar or sacral. Image guidance (fluoroscopy or CT) and any contrast injection are included in these codes : Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical, thoracic, lumbar, or sacral. Imaging guidance (fluoroscopy or CT) and injection of contrast are inclusive components of these codes.

9 Page 9 of : Myelography, (cervical, thoracic, lumbar or sacral), radiological supervision and interpretation. These codes include fluoroscopic guidance for subarachnoid puncture for diagnostic radiographic myelography. The above codes either 1.) include fluoroscopic guidance in the code descriptor, which is an inclusive component of the procedure, or 2.) cannot be reported together with the spinal injection code and should not be billed separately. Exception: The following CPT codes for interlaminar epidural steroid injections can be billed with code 77003: : Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical, thoracic, lumbar or sacral (caudal) : Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervica, thoracic, lumbar or sacral (caudal). Interlaminar versus Transforaminal Epidurals: Two approaches to gain access to the epidural space (which is inside the bony canal but outside the dura mater enveloping the spinal cord) are commonly used: -Interlaminar approach: involves insertion of an injection needle into the epidural space midway between two adjacent vertebrae 1. Posterior approach is less risky and does not always require fluoroscopic guidance 2. Since fluoroscopy is optional and not included in the code description, code may be billed separately (in addition to) the epidural injection codes as above 3. Thus, billing code in addition to codes or IS ACCEPTABLE -Transforaminal approach: involves insertion of an injection needle into the intervertebral neural foramen (or hole) where the nerve root exits the spine. 1. Oblique approach is riskier because it involves placement of the needle into very close proximity to the spinal arteries. Thus, this procedure would not normally be done without fluoroscopic guidance. In addition, the codes for these type of epidural injections contains fluoroscopic (or CT) guidance within the code description itself. Thus, billing code in addition to codes IS NOT ALLOWED. 2. Fluoroscopically guided transforaminal epidurals are thought by some providers to be superior to interlaminar injections because they are delivering the targeted solution closer to the nerves thought to be generating the pain.

10 Page 10 of There is some controversy regarding the risks and benefits of the different types of therapeutic spinal injections. Some of these issues are discussed in the following link: Note: CPT codes 76942, 77002, 77003, 77012, and describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localization 7. Thus, even if a patient had several spinal injections performed (example, multi-level facet joint injections to the lumbar spine), code could only be billed once for that particular patient encounter. CPT/HCPCS Codes: 64490, 64491, 64492, 64493, 64494, 64495, 64622, 64623, 64626, 64627, Effective Date: August 10, 2011 Reviewed Annually: November 11, 2015 Revised: February 13, 2013 May 8, 2013 March 5, 2014 Bibliography: 1. Aetna Clinical Policy Bulletin: Selective Nerve Root Blocks; Number: Aetna Clinical Policy Bulletin: Back Pain Invasive Procedures; Number: Cigna Medical Coverage Policy: Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, Number Anthem Medical Policy: Percutaneous Vertebroplasty and Percutaneous Kyphoplasty; Surg. # American Medical Association Current Procedural Terminology cpt 2013 Professional Edition. 6. Harms of Epidural Steroid Injections Examined. Pain-Topics.org: News/Research Updates-Thursday January 5, 2012,SB.Leavitt,MA,PhD. Weblink: 7. National Correct Coding Initiative Policy Manual For Medicare Services-Chapter IX: Radiology Services-CPT Codes ; Section G, Number 3; Revision Date: 1/1/2013. Weblink:

11 Page 11 of 11 nited/ 8. Medicare Local Coverage Determination (LCD) for Paravertebral Facet Joint Block and Facet Joint Denervation (L28288); Primary Geographic Jurisdiction (California Southern); Revision Effective Date For services performed on or after 07/19/ Apollo Medical Review Criteria - Pain (Evaluation & Management) 10. National Guidline Clearinghouse Guideline Summary NGC-7160: American College of Occupational and Environmental Medicine. Chronic pain. In: Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); p [1557 references] 11. UpToDate: Christopher L Knight, MD, Richard A Deyo, MD, MPH, Thomas O Staiger, MD, Joyce E Wipf, MD Treatment of acute low back pain (PEER REVIEWARTICLE) 12. UpToDate: Roger Chou, MD Subacute and chronic low back pain: Nonsurgical interventional treatment (PEER REVIEWARTICLE) 13. Aetna Clinical Policy Bulletin: Selective Nerve Root Blocks; Number: Aetna Clinical Policy Bulletin: Back Pain Invasive Procedures; Number: Cigna Medical Coverage Policy: Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, Number Anthem Medical Policy: Percutaneous Vertebroplasty and Percutaneous Kyphoplasty; Surg. # American Medical Association Current Procedural Terminology cpt 2013 Professional Edition 18. Harms of Epidural Steroid Injections Examined. Pain-Topics.org: News/Research Updates-Thursday January 5, 2012,SB.Leavitt,MA,PhD. Weblink: National Correct Coding Initiative Policy Manual For Medicare Services-Chapter IX: Radiology Services-CPT Codes ; Section G, Number 3; Revision Date: 1/1/2013. Weblink: Official Disability Guidelines, 2013: Treatment,Low Back Pain, Sacroiliac Joint Blocks. 21. Boston Medical Center HealthNet Plan-Medical Policy: Sacroiliac Joint Injections for Chronic Lob Back Pain. Policy Number: OCA: Current Effective Date: 6/1/ HealthNet: National Medical Policy:Sacroiliac Joint Injections: Policy Number NMP66: Effective Date: October 2003; Updated: January HealthPartners:Sacroiliac Joint Pain Treatment Procedures: Medicare Local Coverage Determination (LCD) for Sacroiliac Joint Injection (L29274); Primary Geographic Jurisdiction (Florida); Revision Effective Date-For services performed on or after 1/1/ Medicare Local Coverage Determination (LDC): Transforaminal Epidural, Paravertebral Facet, and Sacroiliac Joint Injections (L27512): Primary Geographic Jurisdiction (District of Columbia, Delaware, Maryland, New Jersey, Pennsylvania): Revision Effective Date-For services performed on or after 4/12/12. Disclaimer IEHP Clinical Authorization Guidelines (CAG) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Authorization Guidelines (CAG) express IEHP s determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. IEHP has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). IEHP makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Authorization Guidelines (CAG). IEHP expressly and solely reserves the right to revise the Clinical Authorization Guidelines (CAG), as clinical information changes.