Clinical Policy Title: Spine pain epidural steroid injections

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1 Clinical Policy Title: Spine pain epidural steroid injections Clinical Policy Number: Effective Date: March 1, 2016 Initial Review Date: January 10, 2013 Most Recent Review Date: June 5, 2018 Next Review Date: June 2019 Policy contains: Epidural steroid injection Radicular pain. Related policies: CP# CP# CP# CP# CP# CP# CP# CP# Spinal cord stimulators for chronic pain Radiofrequency ablation treatment for spine pain Spinal surgeries Intravenous lidocaine for chronic regional pain Biofeedback for chronic pain Spine pain facet joint injections Spine pain trigger point injections Percutaneous vertebroplasty, kyphoplasty, sacroplasty ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select Health of South Carolina s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peerreviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina s clinical policies are not guarantees of payment. Coverage policy Select Health of South Carolina considers the use of epidural steroid injections (e.g., depo-medrol) with or without a local anesthetic (e.g., lidocaine) for acute (duration less than three months) spinal pain and chronic spinal pain with radiculopathy medically necessary when all of the following criteria are met (Sharma 2017, Mehta 2017, Vorobeychik 2016, Schilling 2016, Kennedy 2014, Landa 2012, Casazza 2012, North American Spine Society [NASS] 2011, Mobaleghi 2011, American Society of Anesthesiologists [ASA] 2010, Ghahreman 2010): Historical and physical examination findings identify irritation in a specific nerve root and anatomic (e.g., magnetic resonance imaging [MRI], computed tomography [CT], or CT- 0

2 myelogram) or physiologic (e.g., nerve conduction velocity-electromyogram [NCV-EMG]) testing shows evidence of nerve root compression or injury in the same nerve root. ; AND The pain is interfering with functional activity of occupation or recreation; AND The pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. Limitations: A maximum of three injections per any six month term shall apply. Select Health of South Carolina considers epidural steroid injection investigational and therefore not medically necessary for all other indications of the spine pain (i.e., those not associated with radicular pain). Alternative covered services: Pharmacotherapy Physical therapy, osteopathic manipulation, chiropractic manipulation. Surgical intervention. Background Back pain is one of the most common causes of disability and pain in America. A contemporary narrative review (Casazza 2012) noted that acute low back pain is one of the most common reasons for adults in the United States to seek medical treatment. Moreover, up to 62 percent of individuals who experience back pain will go on to experience recurrent episodes of the condition, usually within one to two years. Common conditions that cause severe acute or chronic low back pain and/or leg pain (sciatica) from nerve irritation include (Casazza 2012): Herniated nucleus pulposus. Lumbar strain/sprain. Spinal stenosis. Vertebral compression fractures. Spondylolisthesis/ spondylolysis. Spondylosis (degenerative disk or facet joint arthropathy). Clinical manifestations of nerve root inflammation include some or all of the following: Radicular pain 1

3 Dermatomal hypesthesia Weakness of muscle groups innervated by the involved nerve root(s) Diminished deep tendon reflexes Positive straight or reverse leg raising tests. An epidural injection delivers steroids into the epidural space around spinal nerve roots to relieve pain in the lumbar, leg, thoracic and cervical areas caused by irritated spinal nerves. In contrast to oral steroids, epidural therapy offers the advantages of a more localized medication delivery to the area of affected nerve roots, thereby decreasing the likelihood of potential systemic side effects, and is particularly effective in the presence of acute nerve root inflammation. As a rule, patients who obtain little relief from the first injection get little benefit from a second or third injection. Those patients with degenerative lumbar canal stenosis and patients who failed previous therapies may significantly improve standing and walking tolerance following transforaminal lumbar steroid injections. However, interventional pain management physicians in many cases do not perform transforaminal epidural injections, preferring the conventional, interlaminar epidural injection. Providers are directed to a set of Red Flag conditions (Appendix A) which may pertain to the circumstance of refractory pain despite injectable treatment. Searches Select Health of South Carolina searched PubMed and the databases of: UK National Health Services Center for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on April 18, Searched terms were: "Injections, spinal (MeSH)","Epidural injection (MeSH)" and "Spinal surgery." We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. 2

4 Findings Epidural spinal injection (ESI) can be administered via a translaminar or transforaminal route, depending on the clinical scenario (Landa 2012). When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) has been shown to provide up to 6 months of pain relief. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. According to practice guidelines issued jointly from the American Society of Anesthesiologists (ASA) Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine, epidural spinal injection with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy. These bodies recommend shared decision making regarding epidural spinal injection which should include a specific discussion of potential complications, particularly with regard to the transforaminal approach. The North American Spine Society (NASS) proposed guidelines for the use of epidural spinal injection in spinal stenosis. Interlaminar epidural steroid injections are suggested to provide short-term (two weeks to six months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term ( months) efficacy. Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery. A multiple injection regimen of radiographically-guided transforaminal epidural steroid injection or caudal injections is suggested to produce medium-term (3 36 months) relief of pain in patients with radiculopathy or neurogenic intermittent claudication (NIC) from lumbar spinal stenosis. Epidural spinal injection has also been endorsed by the Association of Pain Management Physicians (APMP) as an integral part of nonsurgical management of radicular pain from lumbar spine disorders (i.e., herniated disc and radiculitis). Ghahreman (2010) found that a significantly greater proportion of patients treated with transforaminal injection of steroid (54 percent) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (seven percent) or transforaminal injection of saline (19 percent), intramuscular steroids (21 percent), or intramuscular saline (13 percent). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. The number of patients who maintained relief diminished beyond 12 months. Kennedy (2014) found particulate-free steroid, such as dexamethasone, should be used as the first line drug in transforaminal epidural spinal injection. Particulate steroid should be used only after failure of particulate-free steroid and with appropriate patient counseling and safeguards, such as digital 3

5 subtraction imaging. Policy updates: During the past twelve months there has been further information published regarding epidural steroid injections for spine pain. A systematic review (Sharma 2017) sought to determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. All pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to grades of recommendation, assessment, development and evaluation. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain. A systematic review (Mehta 2017) found there was no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical epidural steroid injection. The authors recommended using nonparticulate steroid when performing cervical epidural steroid injection. In patients with lumbar radiculopathy due to stenosis or disk herniation, epidural steroid injection using particulate versus non-particulate was equivocal in reducing pain and improving function. The authors recommended the use of nonparticulate steroids for lumbar epidural steroid injection in patients with lumbar radicular pain. There was insufficient information to make a recommendation of one steroid preparation over the other in lumbar epidural steroid injection. In 2017, a systematic review (Vorobeychik 2016) found only limited evidence supporting the effectiveness of epidural steroid injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis. The procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. The quality of the evidence for this practice was adjudged to be very low. In a narrative review, Schilling (2016) described targeted interventional delivery of corticosteroids as a mainstay of treatment for spinal pain syndromes because this approach has a wider therapeutic index than other approaches. The authors reported that the best evidence for analgesic efficacy is in subacute radicular syndromes associated with new-onset or recurrent lumbar radiculitis. Complications of the treatment typically relate to drug delivery technique by the physician as opposed to the steroid itself; however, considerable uncertainty exists concerning which patients with chronic pain are most likely to benefit from corticosteroid injections, and optimizing treatment options to the specific spinal pain 4

6 syndromes remains a major challenge. Summary of clinical evidence: Citation Sharma (2017) The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Mehta (2017) Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. Vorobeychik (2016) Content, Methods, Recommendations A systematic review sought to determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. All pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to Grades of Recommendation, Assessment, Development and Evaluation. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain. A systematic review found there was no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical epidural steroid injection. The authors recommended using nonparticulate steroid when performing cervical epidural steroid injection (Grade of Recommendation: B). In patients with lumbar radiculopathy due to stenosis or disk herniation, epidural steroid injection using particulate versus non-particulate was equivocal in reducing pain (Grade of Recommendation: B) and improving function (Grade of Recommendation: C). The authors recommended the use of nonparticulate steroids for lumbar epidural steroid injection in patients with lumbar radicular pain (Grade of Recommendation: B). There was insufficient information to make a recommendation of one steroid preparation over the other in lumbar epidural steroid injection (Grade of Recommendation: I). Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. A systematic review found only limited evidence supporting the effectiveness of epidural steroid injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis. The procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. The quality of the evidence for this practice was adjudged to be very low. 5

7 Citation Schilling (2016) Corticosteroids for pain of spinal origin: epidural and intraarticular administration. Kennedy (2014) Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Landa (2012) Outcomes of interlaminar and transforaminal spinal injections. APMP (2012) Practice guidelines: interventional techniques in the management of chronic pain: part 1.0. Content, Methods, Recommendations Intervention with corticosteroids remains a mainstay of treatment for spinal pain syndromes. Evidence for analgesic efficacy is best associated with subacute radicular syndromes associated with new-onset or recurrent lumbar radiculitis. Complications of the treatment typically relate to drug delivery technique by the physician. RCT of 78 patients promoted particulate-free steroid, such as dexamethasone, as the drug of choice in transforaminal ESI. Recommended particulate steroid (e.g., triamcinolone) use only after failure of particulate-free steroid and with appropriate patient counseling and safeguards, such as digital subtraction imaging. Epidural spinal injections can be administered via a translaminar or transforaminal route, depending on the clinical scenario. When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) have been shown to provide up to six months of pain relief, though long-term benefits are less reliable. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. RCT evaluated the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in the management of chronic neck pain and upper extremity pain with disc herniation and radiculitis. One-hundred twenty subjects were randomly assigned to one of two groups: o Group I members received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 ml). o Group II members received 0.5% lidocaine, 4 ml, mixed with 1 ml of nonparticulate betamethasone. Primary outcome measure was 50 improvement in pain and function. Outcome assessments included Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), opioid intake, employment, and changes in weight. Significant pain relief and functional status improvement ( 50%) was demonstrated in 72% of members who received local anesthetic only and 68% who received local anesthetic and steroids. In the successful group of participants, significant improvement was illustrated in 77% 6

8 Citation NASS (2011) Diagnosis and treatment of degenerative lumbar spinal stenosis. Web site. Mobaleghi (2011) Comparing the effects of epidural methylprednisolone acetate injected in patients with pain due to lumbar spinal stenosis or herniated disks: a prospective study. ASA (2010) Content, Methods, Recommendations in local anesthetic group and 82% in local anesthetic with steroid group. Investigators concluded cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for members with cervical disc herniation and radiculitis. Promulgated guidelines for the use of ESI in spinal stenosis. Interlaminar epidural steroid injections are suggested to provide short-term (two weeks to six months) symptom relief in patients with neurogenic claudication or radiculopathy. Conflicting evidence exists concerning long-term ( months) efficacy. Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery. A multiple injection regimen of radiographically-guided transforaminal epidural steroid injection or caudal injections is suggested to produce medium-term (3 36 months) relief of pain in patients with radiculopathy or neurogenic intermittent claudication (NIC) from lumbar spinal stenosis. Interventional study compared long-term effects of ESI in herniated disks (HD) and lumbar spinal stenosis (LSS) A total of 60 subjects with radicular pain due to HD (n = 32) or LSS (n = 28) were enrolled and followed over a 9-month period. Methylprednisolone acetate 80 mg plus 0.5% bupivacaine 10 mg were diluted in normal saline up to a total volume of 10 ml, and injected into the epidural space. The amount of pain based on numeric pain score, level of activity, and subjective improvement were reported by members after two and six months by telephone. Demographic data were analyzed with the chi-square test. The differences in numeric pain scale scores between the two groups at different times were analyzed with the t- test. There were no differences between HD and LSS members regarding age, sex, and average duration of pain prior to ESI. The degree of pain was significantly higher in LSS members in comparison with HD members in the pre-injection period. The amount of pain was significantly reduced in both groups two months after injection. This pain reduction period lasted for six months in the HD group, but to a lesser extent in LSS members (P < 0.05). Investigators concluded epidural methylprednisolone injection has less analgesic effect in LSS, with less permanent effect in comparison with HD. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the Studies with observational findings on both interlaminar and transforaminal epidural steroid administration with or without local anesthetics report back pain relief for assessment periods ranging from 2 weeks to 3 months and neck pain relief for assessment periods ranging from 1 week to 12 months. RCTs are equivocal regarding the efficacy of interlaminar or transforaminal epidural steroids with local anesthetics compared with epidural local anesthetics alone for back, leg, or neck pain for assessment periods ranging from 3 weeks to 3 months. 7

9 Citation American Society of Regional Anesthesia and Pain Medicine. Ghahreman (2010) Content, Methods, Recommendations The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Found that a significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (seven percent) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. The number of patients who maintained relief diminished beyond 12 months. References Professional society guidelines/other: American College of Physicians and the American Pain Society. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. Web site. Accessed April 18, American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine. 2009; 14(10): American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Web site. Accessed April 18, Hayes Inc., Hayes Medical Technology Report. Epidural Steroid Injections for Cervical Radiculopathy. Lansdale, Pa. Hayes Inc.; September, Hayes Inc., Hayes Medical Technology Report. Epidural Steroid Injections for Low Back Pain and Sciatica. Lansdale, Pa. Hayes Inc.; January, Health Care Guideline: Adult Acute and Subacute Low Back Pain. Institute for Clinical Systems Improvement. Web site pdf Accessed April 18,

10 North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Web site. Accessed April 18, North American Spine Society (NASS). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Web site. Accessed April 18, Peer-reviewed references: Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline. Spine Jnl. 2011; 11(1): Casazza B. Diagnosis and treatment of acute low back pain. Am Fam Physician Feb 15;85(4): Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain, Pain Med. 2010;11(8): Juch J, Maas E, Ostelo R, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic LowBack Pain The Mint Randomized Clinical Trials. JAMA. 2017;318(1): Kennedy D, Plastaras C, Casey E, et al. Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Med. 2014;15(4): Landa J, Kim Y. Outcomes of interlaminar and transforaminal spinal injections. Bull NYU Hosp Jt Dis. 2012;70(1):6-10. Mehta P, Syrop I, Singh JR, Kirschner J. Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. PM R May;9(5): doi: /j.pmrj Epub 2016 Nov 30. Review. PubMed PMID: Mobaleghi J, Allahdini F, Nasseri K, et al. Comparing the effects of epidural methylprednisolone acetate injected in patients with pain due to lumbar spinal stenosis or herniated disks: a prospective study. Int J Gen Med. 2011; 4: Schilling LS, Markman JD. Corticosteroids for Pain of Spinal Origin: Epidural and Intraarticular Administration. Rheum Dis Clin North Am Feb;42(1):

11 Sharma AK, Vorobeychik Y, Wasserman R, et al; Standards Division of the Spine Intervention Society. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med Feb 1;18(2): doi: /pm/pnw131. PubMed PMID: Vorobeychik Y, Sharma A, Smith CC, et al. Standards Division of the Spine Intervention Society. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med. 2016;17(12): CMS National Coverage Determination (NCDs): NCD, 160.1: Induced Lesions of Nerve Tracts. CMS Medicare Coverage Database Web site. Accessed April 18, Local Coverage Determinations (LCDs): L35148 Lumbar epidural steroid injections. CMS Medicare Coverage Database Web site. KeyWord=epidural+steroid+injection&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABA BAAAA& Accessed April 18, L34807 Lumbar epidural steroid injections. CMS Medicare Coverage Database Web site. KeyWord=epidural+steroid+injection&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABA BAAAA& Accessed April 18, Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in accordance with those manuals. CPT Code Description Comment Injection(s), of Diagnostic or Therapeutic Substance(s) (Including 10

12 CPT Code Description Comment 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 or thoracic 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; 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; cervical or thoracic 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; lumbar or sacral (caudal) Injection(s) anesthetic agent and /or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT). Cervical or thoracic, single level Cervical or thoracic each additional level Add on code Injection, Anesthetic Agent and/or Steroid, Transforaminal Epidural, With Imaging Guidance (Fluoroscopy or CT); Lumbar or Sacral; Single Level Injection, Anesthetic Agent and/or Steroid, Transforaminal Epidural, With Imaging Guidance (Fluoroscopy or CT); Lumbar/Sacral; Each Additional Level (List Separately in Addition to Code for Primary Procedure) Add on code ICD-10 Code Description Comment B02.23 Postherpetic polyneuropathy B02.7 Disseminated zoster B02.8 Zoster with other complications B02.9 Zoster without complications G54.4 Lumbosacral root disorders, not elsewhere classified M08.1 Juvenile ankylosing spondylitis M25.78 Osteophyte, vertebrae M43.00 M43.09 Spondylolysis M43.10 M43.19 Spondylolisthesis M45.1 M45.9 Ankylosing spondylitis M46.00 M46.09 Spinal enthesopathy M46.40 M46.49 Discitis, unspecified 11

13 ICD-10 Code Description Comment M M Anterior spinal artery compression syndromes M Vertebral artery compression syndromes, occipito-atlanto-axial region M Vertebral artery compression syndromes, cervical region M Vertebral artery compression syndromes, site unspecified M47.11 M47.16 Other spondylosis with myelopathy M M47.28 Other spondylosis with radiculopathy, site unspecified M M Spondylosis without myelopathy or radiculopathy M M Other spondylosis M47.9 Spondylosis, unspecified M48.00 M48.07 Spinal stenosis, site unspecified M48.10 M Ankylosing hyperostosis M48.20 M48.27 Kissing spine M48.30 M48.38 Traumatic spondylopathy M48.8X1 M48.8X9 Other specified spondylopathies M48.9 Spondylopathy, unspecified M50.00 M50.03 Cervical disc disorder with myelopathy M50.10 M50.13 Cervical disc disorder with radiculopathy M50.20 M50.23 Other cervical disc displacement M50.30 M50.33 Other cervical disc degeneration M50.80 M50.83 Other cervical disc disorders M50.90 M50.93 Cervical disc disorder, unspecified M51.04 M51.06 Intervertebral disc disorders with myelopathy M51.14 M51.17 Intervertebral disc disorders with radiculopathy M51.24 M51.27 Other intervertebral disc displacement, thoracic region M51.34 M51.37 Other intervertebral disc degeneration M51.84 M51.9 Other intervertebral disc disorders 12

14 ICD-10 Code Description Comment M53.0 Cervicocranial syndrome M53.1 Cervicobrachial syndrome M54.10 M54.18 Radiculopathy M54.2 Cervicalgia M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M54.32 Sciatica, left side M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M54.5 Low back pain M54.6 Pain in thoracic spine M79.2 Neuralgia and neuritis, unspecified M96.1 Postlaminectomy syndrome, not elsewhere classified M99.20 M99.23 Subluxation stenosis of neural canal M99.30 M99.33 Osseous stenosis of neural canal M99.40 M99.43 Connective tissue stenosis of neural canal M99.50 M99.53 Intervertebral disc stenosis M99.60 M99.63 Osseous and subluxation stenosis of intervertebral foramina M99.70 Connective tissue and disc stenosis of intervertebral foramina of head region HCPCS Level II Code J1020 J1030 J1040 G0260 Description Injection, methylprednisone acetate, 20 mg Injection, methylprednisone acetate, 40 mg Injection, methylprednisone acetate, 80 mg Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography Comment Appendix A. Red flag symptoms may be indicative of more serious neurologic conditions from spinal instability. These may be categorized as the following: Suspected unstable fractures of the spine which may be evidenced by a history of a recent fall or injury, and major motor weakness of a limb, or progressive neurological deficits, or 13

15 bladder or bowel dysfunction. History of cancer with suspicion of metastatic spread which may be evidenced by major motor weakness of a limb, or pain which increases at night or at rest, or progressive neurological deficits, or bladder or bowel dysfunction, or unexplained weight loss of more than ten pounds in six weeks. Infection with suspicion of an epidural abscess/diskitis which may be evidenced by progressive neurological deficits, or fever of F for more than 48 hours, and C- reactive protein >10 mg/l, or recent (within two weeks) interventional spine procedures, or ESR >20 mm/hr., or immunocompromised (either immunodeficiency from any cause or IV drug abuse). Cauda equina syndrome which may be evidenced by bladder or bowel dysfunction, or saddle anesthesia, or progressive neurological deficits. 14