Medical Affairs Policy

Transcription

1 Medical Affairs Policy Service: Back and Nerve Pain Procedures - Radiofrequency Ablation, Facet and Other Injections PUM Cryoablation Medial Branch Neuroablation Radiofrequency Neuroablation Dorsal Ramus Injection Medial Branch Neurolysis Sacroiliac Joint Ablation Facet Neurotomy Medial Branch Neurotomy Sacroiliac Neuroablation Facet Rhizotomy Occipital Nerve Ablation Supraorbital Nerve Ablation Genicular Nerve Ablation Paravertebral Facet Joint Block Supatrochlear Nerve Ablation Genicular Nerve Block Posterior Ramus Injection Zygapophysial Joint Injection Lateral (Sacral) Branch Nerve Block Pulsed Radiofrequency Ablation (PRFA) Zygapophysial Joint Neurotomy Medial Branch Block (MBB) Radiofrequency Denervation Related Medical Policies: Back Pain Procedures-Epidural Injections Back Pain Procedures-Sacroiliac Joint and Coccydynia Treatments Non-covered Services and Procedures Occipital Nerve Block and Headache Treatments Medical Policy Committee Approval 06/16/17 Effective Date 08/21/17 Prior Authorization Needed Yes Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, medical.policies@wpsic.com. Description: Many member health plans have set maximum limits for pain injections per plan year or calendar year. These services are covered subject to medical necessity review. If a limit is not specified in the member s health plan, the maximum follows the medical Page 1 of 14

2 necessity guidelines in this policy. If a year is not described in the member health plan (e.g. per calendar year), a year is defined as the 12-month period starting from the date of service of the first approved injection. There is controversy among interventional pain management specialists regarding how to diagnose and manage spinal pain; there is a lack of consensus regarding the type and frequency of spinal interventional techniques for treatment of spinal pain. Much of the published evidence is conflicting, limited by the heterogeneous character of the patient populations, variability of treatment methods, and variability of procedure (injection method and injection site), co-administration of drugs, postoperative evaluation times, and nonstandardization of outcome measures. RCTs often compare the experimental treatment with a standard but also unproven treatment. This policy addresses diagnosis of facet joint pain using facet and medial branch block injections in preparation for treatment of spine pain using neuroablation. Therapeutic facet and medial branch injections are considered experimental investigational and unproven to affect health outcomes. Non-pulsed Continuous RadioFrequency Ablation / neuroablation (CRFA, and RFA) also known as thermal RFA, percutaneous radiofrequency facet denervation (RF denervation), RF coagulation, RF lesioning, RF neurolysis, radiofrequency (RF) facet joint rhizotomy, or facet neurotomy, involves percutaneous placement of a needle or electrode that destroys the nerves around the facet joint. Once the probe is placed, nerves are then targeted continuously (typically, for 40 to 90 seconds at temperatures of 60 to 90 C) resulting in destruction of the medial branch nerve that innervates a symptomatic facet joint. The procedure is used to interrupt pain impulses. It is performed under fluoroscopic guidance. Neuroablation is frequently effective for extended periods of time. The necessity of a repeat neuroablation procedure is dependent on the effectiveness of the previous procedure. If the neuroablation procedure was effective for less than 6 months, it is unlikely that a repeat procedure will provide any additional benefit. The duration of action of a neuroablation procedure, as reported in the literature, is inconsistent and varies widely from six to eighteen months. Pulsed Radiofrequency Ablation (PRFA) (also known as cold radiofrequency) has been introduced as a non-ablative alternative to RFA for a wide variety of painful conditions. PRFA delivers short bursts of radiofrequency current at temperatures around 42 C -45 C and allows the tissue to cool between bursts. This technique is expected to reduce the risk of destruction of neighboring tissue. It does not destroy targeted nerves. It is performed under fluoroscopic guidance. A facet joint injection is the injection of a local anesthetic with or without steroid into one or more of the facet joints of the spine. A medial branch nerve block is an injection of a local anesthetic near the medial branch nerves that innervate the facet joint. Both the diagnostic facet joint injection and the diagnostic medial branch nerve block are performed Page 2 of 14

3 to determine whether the facet joint is the source of the pain symptoms, in order to guide future treatment such as neuroablation. Zygapophysial Joint Injection, Paravertebral Facet Joint Block, Dorsal Ramus Injection, Posterior Ramus Injection, have been proposed to diagnose and treat facet region pain. Although the techniques of injection vary, the terms are often used interchangeably. Non-Radicular pain, for purposes of this policy, is pain that does not follow the pattern of radiation from the spine into the extremity along the course of the spinal nerve root; radicular pain typically follows the pattern of the sensory dermatome associated with the nerve root(s) identified. The pain may also be described as a burning or tingling sensation. Levels of injection / ablation: The level of injection/ablation of spinal nerves is reported, coded, and billed by facet joint location regardless of which or how many nerves innervate (are associated with) the vertebra at that joint level. Billing codes are intended to report ALL the nerves that are associated with the facet joint being treated. The second or third additional level refers to the second or third facet joint not additional nerves being treated. For example: The L3-L4 facet joint receives partial innervation from the medial branch of the L2 spinal nerve that exits between the L2-L3 vertebrae and partial innervation from the medial branch of L3 spinal nerve that exits between the L3-L4 vertebrae. The L4-L5 facet joint is innervated by medial branches of the L3 and L4 nerves. The L5-S1 joint is innervated by the medical branch of L4 and the dorsal ramus of L5. Some providers maintain that there is also innervation from the S1 spinal nerve. Sacroiliac (SI) joint injection is an injection of local anesthetic and / or a steroid into the articular space between the spinal column and pelvis. SI joint pain is usually described as low back and buttock pain. Pain symptoms are presumably related to an inflammatory process in the joint between the spinal column and pelvis. Injections have been performed for both diagnostic and therapeutic purposes. Other interventions that have been proposed to treat SI join pain include Sacroiliac Joint Ablation, Sacroiliac Neuroablation, and Lateral (Sacral) Branch Nerve Blocks. See the Back Pain-Sacroiliac Joint and Coccydynia Treatment Medical Policy. Indications of Coverage: Note: Diagnostic facet and medial branch block injections are considered medically necessary only in the context of preparation for treatment of spine pain using neuroablation, and after conservative treatment and evaluation as described in A, B, and C below. Therapeutic facet and medial branch injections are considered experimental investigational and unproven to affect health outcomes in all other situations. Therapeutic Page 3 of 14

4 Sacroiliac Joint (SI joint) injections and SI Joint neuroablation are addressed in the Back Pain-Sacroiliac Joint and Coccydynia Treatments Medical Policy. Neuroablation/facet injection of the cervical or lumbar spine regions is considered medically necessary when all the following criteria are met: A. Chronic axial back or neck pain symptoms (at least three months in duration) without radicular pain symptoms B. Failure of a 6-week trial in the last 6 months of more conservative therapies including all of the following: 1. Medications such as anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin, or pregabalin. 2. Therapy: physical therapy/chiropractic manipulations performed, at some point, after the onset of the current episode of symptoms (Documentation of therapy administered by a Certified Athletic Trainer or regular participation in programs such as the Arthritis Foundation Exercise Program may also meet medical criteria for therapy) C. Symptoms are not attributed to another identified source (such as disc herniation, radiculitis, spinal stenosis, tumor, infection, fracture) D. After A, B, and C above are met: Documentation of appropriately performed comparative positive diagnostic cervical or lumbar facet or medial branch anesthetic blocks. Due to the high rate of placebo effect and confounding variables such as addition of steroid to the injection, a confirmatory injection, using an anesthetic with a different duration of action than the initial diagnostic block is required. Analgesic / anesthetic onset and duration must be concordant with the expected minimum onset of relief and duration of action for the specific local anesthetic used as reported in pharmaceutical literature. Onset of action is typically 3-30 minutes. Duration of commonly used anesthetic without epinephrine is: Lidocaine minutes Mepivicaine minutes Bupivacaine minutes Ropivocaine minutes NOTE: Prior authorization is required for each diagnostic block 1. The first diagnostic block must provide significant (at least 50%) relief from baseline scores following the procedure. Documentation of the patient response: onset AND duration of analgesia must be reported. And, Page 4 of 14

5 the patient must demonstrate ability to perform previously painful maneuvers. If the diagnostic block does not provide relief then a second diagnostic block is considered not medically necessary 2. A confirmatory injection is medically necessary when all of the following are documented: Documentation of the patient response after the first injection is provided including onset AND duration of analgesia, report of patient s changes in functional status. If there is no documentation of the anesthetic used and the onset and duration of analgesia, the injection will be considered therapeutic outcomes. The second /confirmatory diagnostic injection must be performed at the same side and same level as the initial injection using anesthetic with a different duration of action. The confirmatory diagnostic injection procedure must be performed a minimum of one week after the initial injection procedure. E. Each level and side to be ablated must have documentation of a positive diagnostic and confirmatory block. If all of the above are met, a maximum of one neuroablation date of service will be approved per 6 months, with a maximum of two levels per ablation. Bilateral ablations will count as one level only if performed on the same date of service. Fluoroscopic or CT guidance is required during medial branch neuroablation. Repeat Neuroablation at the same facet joint level and side of a previous ablation: If a limit is not specified in the member health plan, neuroablation done at the same level on the same side can be repeated when symptoms recur after 6 months, if there is documentation of at least a 50% reduction in pain sustained over at least 6 months following the ablation. Repeat diagnostic facet/mbb injections in preparation for repeat neuroablation are considered not medically necessary. If chemical agents (for example phenol or alcohol) are planned for the ablation procedure, there must be documentation of the contraindication to thermal neuroablation (for example, spinal instrumentation, pacemaker, implantable cardiac defibrillator). More than 4 diagnostic facet or MBB injections regardless of location/level in a year are considered not medically necessary. A bilateral injection will be counted as one injection. Note: A bilateral injection can only be billed if both sides are injected on the same date of service. If the left and right injections are performed on two separate (sequential) dates of service, this will count as 2 injections. Page 5 of 14

6 Limitations of Coverage: A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements. B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, deny as experimental, investigational, and unproven to affect health outcomes. C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary. D. Therapeutic injections including: facet joint, medial branch block injections (MBB), zygapophysial joint injection, paravertebral facet joint injection, dorsal ramus injection, and posterior ramus injections are all considered experimental, investigational, and unproven to affect health outcomes. E. Destruction of the medial branch nerve by any method other than thermal neuroablation (for example, cryoablation or phenol), without documentation of the contraindication to thermal ablation, is considered experimental, investigational, and unproven to affect health outcomes. F. Neuroablation is considered investigative in any of the following situations as there is insufficient peer-reviewed scientific literature supporting neuroablation in these situations: 1. When fluoroscopic or CT guidance is not used during the procedure; 2. For any nerve other than the medial branch nerve (including but not limited to occipital, genicular, supraorbital, and supratrochlear nerves) See also Occipital Nerve Block and Headache Treatments medical policy and Non-Covered Services and Procedures medical policy) 3. When there is no diagnostic block to identify the appropriate level and side to be treated. 4. Pulsed Radiofrequency (also known as: Cold Radiofrequency, cold ablation, PRF, PRFA) is used. G. Lumbar and sacral medial branch neuroablation for treating sacroiliac joint pain is considered experimental, investigational, and unproven to affect health outcomes. See SI Joint Treatments and Coccydynia Treatments medical policy. H. The following treatments for management of back/ buttocks pain or SI joint dysfunction are considered experimental, investigational, and unproven to affect health outcomes: Sacroiliac joint ablation, Sacroiliac Neuroablation, sacroiliac Page 6 of 14

7 fusion, diagnostic Lateral (Sacral) Branch Nerve Blocks and diagnostic sacroiliac joint injections in preparation for an ablation or fusion. See SI joint Treatments and Coccydynia Treatments medical policy. I. Neuroablation is considered not medically necessary when more than one neuroablation procedure on one side of a particular level of the spine is performed less than 6 months after an earlier neuroablation procedure. J. Neuroablation (facet neurotomy) and facet injection in preparation for ablation of the thoracic spine is considered experimental, investigational, unproven to affect health outcomes. K. Neuroablation (facet neurotomy) for treatment of cervicogenic headache is considered experimental, investigational, and unproven to affect health outcomes. See Occipital Nerve Block and Headache Treatments Medical Policy L. Laser facet denervation is considered experimental, investigational, and unproven to affect health outcomes. M. Injection of a caustic agent such as phenol, alcohol, or sodium morrhuate into a facet joint is considered experimental, investigational, and unproven to affect health outcomes. N. If the use of fluoroscopic or CT guidance is not documented, the facet joint injection or medial branch nerve block is considered experimental, investigational, and unproven to affect health outcomes. O. A facet joint injection and/or medial branch nerve block in the presence of primary radicular symptoms (pain, numbness, or tingling in an extremity) or other unexplained neurologic symptoms, excluding those symptoms with peripheral causes (for example, carpal tunnel syndrome, diabetic neuropathy) is considered not medically necessary. P. A facet joint arthrogram in conjunction with a facet joint injection is included in the fluoroscopic guidance for the injection and is considered not medically necessary. Q. If more than one type of pain treatment is requested/ performed on the same day, only one type will be considered medically necessary at the discretion of the health plan. R. More than two vertebral levels injected or ablated during a treatment setting are considered not medically necessary. Page 7 of 14

8 S. Cryoablation for the treatment of lumbar facet joint pain is considered experimental, investigational, and unproven to affect health outcomes. T. Ultrasound guidance for facet injection or MBB is considered experimental, investigational, and unproven to affect health outcomes. Documentation Required: Office notes including documentation of the symptoms that suggest the presence of facet joint pathology and exclude any correctable spinal pathology condition (for example, spinal cord tumor, severe spinal stenosis, infection, or intervertebral disc disease requiring surgical treatment, such as a large disc herniation) Documentation of the failure of more conservative therapies For the second (confirmatory) injection, office notes documenting the results of the first injection, as indicated above. Documentation of the effect of the first injection may include a patient diary or office telephone records. Documentation of Functional Status pre-and post-injection which includes: o Work status/ Work restrictions o Specific Activities of Daily Living (ADL) o Current Pain use o Measurable Physical status indicators (e.g. Range of Motion, Muscle strength) Medial Branch References: 1. Boswell M, Trescot A, Datta S, Schultz D, Hansen H, Abdi S, Sehgal N, Shah R, Singh V, Benyamin R, Patel V, Buenaventura R, Colson J, Cordner H, Epter R, Jasper J, Dunbar E, Atluri S, Bowman R, Deer T, Swicegood J, Staats P, Smith HS, Burton A, Kloth D, Giordano J, Manchikanti L. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. American Society of Interventional Pain Physicians. Pain Physician. Jan Available at: Accessed: 24 Aug Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine May 15; 25(10): Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2003; 6: Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996; 335: Page 8 of 14

9 5. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm II J, Parr AT, Schultz DM, Smith HS, Wolfer LR, and Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12: Available at: BasedGuidelinesforInterventionalTechniquesintheManagementofChronicSpin.pdf. Accessed: 25 Aug Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H,. Radiofrequency denervation for neck and back pain (Cochrane Review). In: The Cochrane Library, Issue 4, Chichester, UK: John Wiley & Sons, Ltd. 7. Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine Nov 1; 29(21): Sehgal N, Dunbar E, Shah R, Colson J. Systematic Review of Diagnostic Utility of Facet (Zygapophysical) Joint Injections in Chronic Spinal Pain: An Update. Pain Physician 2007; 10: Washington State Department of Labor and Industries. Guideline on diagnostic facet medial nerve branch blocks and facet neurotomy. Provider Bulletin 2005 Aug; (PB 05-11): MCG Ambulatory Care 19 th Edition ACG:A-0218 (AC) Facet Neurotomy 11. Hayes Medical Directory. Radiofrequency Ablation for Sacroiliac Joint Pain. Published Date: August 21, Annual Review: July 22, Hayes Search & Summary. Radiofrequency Ablation (RFA) for Chronic Thoracic Back Pain. October 2, Archived 2 Nov Correspondence from Hayes Inc. 29 April 2015: a review of the literature since archival has revealed no new information that would change the decision. 13. UpToDate. Sub-acute and chronic low back pain: Nonsurgical interventional treatment. Literature review current through: Feb This topic last updated: May 13, Washington State Health Care Authority Health Technology Assessment. Facet Neurotomy. Final Adoption. May 16, Available online at: Manchikanti L, Salahadin A, Sairam A. et al. An Update of Comprehensive Evidence- Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Part II: Guidance and Recommendations. April Available at: Accessed: 30 March Page 9 of 14

10 References Added Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain. AHRQ Technology Assessment Report. Revised publication July 10, Available at: Accessed 5/17/16 2. Hayes Medical Directory. Radiofrequency Ablation for Sacroiliac Joint Pain. Published Date: August 21, Annual Review: June 11, Hayes Medical Technology Directory. Nerve Blocks for the Treatment of Chronic Nonmalignant Pain Published Sept 22, Annual Review Aug 2, Hayes Search and Summary Radiofrequency Ablation for Thoracic Back Pain Oct 8, MCG Ambulatory Care 20 th Edition ACG: A-0218 (AC) Facet Neurotomy 6. Up to Date. Subacute and chronic low back pain: Nonsurgical interventional treatment. Literature review current through: April This topic last updated: Apr 1, 2016 Facet Joint Injection References: 1. Bogduk N. A narrative review of intra-articular corticosteroid injections for low back pain. Pain Med Jul-Aug; 6(4): Boswell M, Trescot A, Datta S, Schultz D, Hansen H, Abdi S, Sehgal N, Shah R, Singh V, Benyamin R, Patel V, Buenaventura R, Colson J, Cordner H, Epter R, Jasper J, Dunbar E, Atluri S, Bowman R, Deer T, Swicegood J, Staats P, Smith HS, Burton A, Kloth D, Giordano J, Manchikanti L. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. American Society of Interventional Pain Physicians. Pain Physician. Jan Available at: Accessed: 8 Mar Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic Assessment of Diagnostic Accuracy and Therapeutic Utility of Lumbar Facet Joint Interventions. Pain Physician Mar-Apr; 12(2): Falco FJ, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, Hayek SM. Systematic Review of Diagnostic Utility and Therapeutic Effectiveness of Cervical Facet Joint Interventions. Pain Physician Mar-Apr; 12(2): Gorbach C, Schmid MR, Elfering A, Hodler J, Boos N. Therapeutic efficacy of facet joint blocks. AJR Am J Roentgenol May; 186(5): Page 10 of 14

11 6. Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, Buenaventura RM, Conn A, Datta S, Derby R, Falco FJE, Erhart S, Diwan S, Hayek SM, Helm S II, Parr AT, Schultz DM, Smith HS, Wolfer LR, Hirsch JA. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12: Available at: BasedGuidelinesforInterventionalTechniquesintheManagementofChronicSpin.pdf.Accessed: 8 Mar No authors listed. Guideline on facet neurotomy. Washington State Department of Labor and Industries. Jan Available at: Accessed: 8 Mar Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine Jan 1; 34(1): Gmyrek, R., Local and Regional Anesthesia. Updated Jul13, Available at Accessed 23/Mar Kapitanyan, R. Toxicity, Local Anesthetics. Updated Apr 9, 2010 Available at: Accessed 23 Mar Washington State Health Care Authority Health Technology Assessment. Spinal Injections. Meeting Date: March 18 th, Final Adoption: June 17 th, MCG Ambulatory Care 19 th Edition ACG:A-0695 (AC) Facet Joint Injection 13. UpToDate. Subacute and chronic low back pain: nonsurgical interventional treatment. Literature review current through: Mar This topic last updated: May 13, Mandel, S, Schilling J, Peterson E, et al. A retrospective analysis of vertebral body fractures following epidural steroid injections. J Bone Joint Surg Am Jun 5; 95(11): Washington State Health Care Authority Health Technology Assessment. Spinal Injections. Meeting Date: March 18 th, Final Adoption: June 17 th, Hayes News-Government. FDA warns of Cortisone Injections. April 28, Manchikanti L, Salahadin A, Sairam A. et al. An Update of Comprehensive Evidence- Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Page 11 of 14

12 Pain. Part II: Guidance and Recommendations. April Available at: Accessed: 30 March References Added Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain. AHRQ Technology Assessment Report. Revised publication July 10, Available at: Accessed 5/17/16 2. Hayes Medical Technology Directory. Nerve Blocks for the Treatment of Chronic Nonmalignant Pain Published Sept 22, Annual Review Aug 2, MCG Ambulatory Care 20 th Edition ACG: A-0695 (AC) Facet Joint Injection 4. UpToDate. Subacute and chronic low back pain: Nonsurgical interventional treatment. Literature review current through Apr 2015 This topic last updated: Apr 1, 2016 References Added Hayes Directory. Radiofrequency Ablation for Facet Joint Denervation for Chronic Low Back Pain. Publication date Dec 01, Hayes Directory. Radiofrequency Ablation for Facet Joint Denervation for Sacroiliac Joint Denervation for Chronic Low Back Pain. Publication date Feb 07, MCG Ambulatory Care 21 st Edition ACG: A-0695 (AC) Facet Joint Injection 4. MCG Ambulatory Care 21 st Edition. ACG: A-0225 (AC) Epidural Corticosteroid Injection 5. UpToDate. Subacute and chronic low back pain: Nonsurgical interventional treatment. Literature review current through: April This topic last updated: Nov 17, UpToDate. Treatment of Neck Pain Literature review current through Apr Topic last updated Dec 21, 2016 Page 12 of 14

13 WPS/Arise Review History: Back Pain Procedures - Radiofrequency Ablation, Facet Joint Injection, and others Implemented 10/01/16, 08/21/17 Medical Policy 06/03/16, 06/16/17 Committee Approval Reviewed 06/16/17 Revised Errata* correction 10/25/16. 06/16/17 (includes title change) Developed 06/03/016- New consolidated policy developed 10/25/17 Errata: Under indications: Neuroablation of the cervical corrected to Neuroablation/facet injection of the cervical Facet Joint Injection and Medial Branch Block: *Retired to Back Pain Procedures - Radiofrequency Ablation, Facet Joint Injection, and others Implemented Medical Policy 06/13/14, 06/12/15, *Retired 06/03/16 effective 09/30/16 Committee Approval Reviewed 06/13/14, 06/12/15 Revised 06/12/15 Developed Medial Branch Neuroablation. *Retired to Back Pain Procedures - Radiofrequency Ablation, Facet Joint Injection, and others Implemented Medical Policy 06/13/14, 06/12/15, *Retired 06/03/16 effective 09/30/16 Committee Approval Reviewed 06/13/14, 06/12/15 Revised 06/12/15 Developed Sacroiliac Joint Treatments and Coccydynia Injections* Retired to Back Pain Procedures - Radiofrequency Ablation, Facet Joint Injection, and others. Coccydynia Injections also retired to Back Pain Procedures Epidural Injections Implemented 01/01/16 Page 13 of 14

14 Medical Policy 09/12/14, 09/11/15, *Retired 06/03/16 effective 09/30/16 Committee Approval Reviewed 09/12/14, 09/11/15 Revised 09/12/14 Developed Note: For review/revision history prior to 2014 see previous Medical Policy or Coverage Policy Bulletin Approved by the Medical Director Page 14 of 14