CMM-201~Facet Joint Injections- Medical Branch Blocks

MedSolutions, Inc. Clinical Decision Support Tool Diagnostic Strategies This tool addresses common symptoms and symptom complexes. Requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or patient s Primary Care Physician (PCP) may provide additional insight. COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES 2014 MedSolutions, Inc. CMM-201~Facet Joint Injections- Medical Branch Blocks MedSolutions, Inc. Clinical Decision Support Tool Common symptoms and symptom complexes are addressed by this tool. Requests for patients with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician may provide additional insight. CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. 2014 MedSolutions, Inc. Comprehensive Musculoskeletal Management Guidelines

COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM-201~Facet Joint Injections/Medial Branch Blocks CMM-201 Facet Joint Injections-Medial Branch Blocks 201.1 Definitions 3 201.2 General Guidelines 3 201.3 Indications and Non-Indications 4 201.4 Procedure (CPT ) Codes 6 201.5 References 6 V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 2 of 10

COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM-201~Facet Joint Injections/Medial Branch Blocks CMM-201.1 Definitions Intra-articular facet joint injections refer to the injection of contrast, followed by the introduction of a local anesthetic and possibly a corticosteroid by inserting a needle under fluoroscopic guidance directly into the facet joint. The procedure is performed to assist in the diagnosis of facet joint pain in anticipation of possibly performing a facet joint denervation/radiofrequency ablation. The positions of the needle should be verified by fluoroscopy and documented with permanent images. Considering the intra-articular blocks are sometimes combined with a corticosteroid, in addition to being diagnostic, they can also be therapeutic in nature. Medial branch blocks refer to the injection of local anesthetic and possibly a corticosteroid along the nerves supplying the facet joints by inserting a needle under fluoroscopic guidance directly adjacent to the joints in the region of the nerves, which supply the joint in question. Even though either procedure can be used to diagnose facet joint pain, a medial branch block is generally considered more appropriate. A positive block is considered to occur when there is at least 80% relief of the pain the patient has been experiencing for the length of time expected for the anesthetic used. CMM-201.2 General Guidelines The determination of medical necessity for the use of intra-articular facet joint injections and medial branch blocks is always made on a case-by-case basis. Based on the lack of both short-term and long-term efficacy of performing therapeutic intra-articular facet joint injections or medial branch blocks as an isolated intervention, all intra-articular facet joint injections and medial branch blocks should be performed in conjunction with an active rehabilitation program or on patients who are actively performing a home exercise program. Injections or blocks performed in isolation without the patient participating in an active rehabilitation program or home exercise program may be considered not medically necessary. Intra-articular facet joint injections and medial branch blocks should be performed using fluoroscopy. Performance of intra-articular facet joint injections or medial branch blocks without the use of fluoroscopic guidance may be considered not medically necessary. Continued... V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 3 of 10

COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM-201.2 General Guidelines Continued... Intra-articular facet joint injections and medial branch blocks should be performed using fluoroscopy. Performance of intra-articular facet joint injections or medial branch blocks without the use of fluoroscopic guidance may be considered not medically necessary. Facet joint injections and medial branch blocks can expose patients to potential complications. Diagnostic intra-articular facet joint injections and medial branch blocks should therefore only be performed with the anticipation that if successful, facet joint denervation procedures (radiofrequency ablation/facet neurotomy) would be considered as an option at the diagnosed levels. In clinical situations where facet joint denervation procedures (radiofrequency ablation/facet neurotomy) are not being considered, the performance of intra-articular facet joint injections or medial branch blocks may be considered not medically necessary. CMM-201.3 Indications and Non-Indications The performance of intra-articular facet joint injections and medial branch blocks may be considered medically necessary for a patient who has been confirmed with facet mediated pain by provocative testing resulting in reproducible pain (i.e., hyperextension, rotation) that has resulted from disease, injury or surgery and has not responded sufficiently to at least four (4) weeks of conservative therapy (exercise, physical methods including physical therapy, chiropractic care, NSAIDs and/or analgesics). Intra-articular facet joint injections and medial branch blocks should only be performed in patients with neck pain or low back pain who do not have a documented and untreated radiculopathy. The performance of intra-articular facet joint injections or medial branch blocks in patients who present with documented evidence of radiculopathy that has been untreated, may be considered not medically necessary. Based on the lack of evidence that a second or confirmatory block prevents the incidence of a false positive response to the radiofrequency facet joint ablation/neurotomy, a repeat intra-articular facet joint injection or medial branch block in most clinical situations may be considered not medically necessary. When diagnostic intra-articular facet joint injections or medial branch blocks are performed (anesthetic only), a positive diagnostic response is recorded when greater than 80% pain relief is reported for 80% of the duration of the effect of the local anesthetic used. When an injection or block is considered positive, a second (confirmatory) block is V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 4 of 10

not medically necessary. When therapeutic intra-articular facet joint injections or medial branch blocks are performed (anesthetic and corticosteroid), a positive response to the procedure is considered when the patient has reported at least a 50% reduction in their pain for at least four (4) weeks. When considering repeat therapeutic facet joint injections/medial branch blocks, they should not be performed more frequently than once every four (4) months. To avoid coming to an improper diagnosis or providing unnecessary treatment, the performance of facet joint injections or medial branch blocks is not medically necessary on the same day of service when performing other spinal injections in the same region. When performing intra-articular facet joint injections or medial branch blocks, no more than three (3) levels should be injected during the same session/procedure. It may be medically necessary to inject the same level or levels bilaterally during the same session/procedure. The performance of injections/blocks on more than three (3) levels may be considered not medically necessary. Facet joint injections and medial branch blocks are not without risk, and can expose patients to potential complications. When performing intra-articular facet joint injections or medial branch blocks, the use of intravenous sedation may be grounds to negate the results of a diagnostic block and; therefore, should be reserved for only those patients with severe anxiety issues. Due to the risk of potential complications, the routine use of intravenous sedation may be considered not medically necessary. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 5 of 10

COMPREHENSIVE MUSCULOSKELETAL MANAGEMENT GUIDELINES CMM-201.4 Procedure (CPT ) Codes This guideline relates to the CPT code set below. Codes are displayed for informational purposes only. Any given code s inclusion on this list does not necessarily indicate prior authorization is required. Preauthorization requirements vary by individual payor. CPT Code Description/Definition Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with 64490 image guidance (fluoroscopy or CT), cervical or thoracic, single level Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not +64491 including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), second level (List separately) Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not +64492 including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), third and any additional level(s) (List separately) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level +64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, second level (List separately) 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, third and any additional level(s) (List separately) 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. CMM-201.5 References 1. Airaksinen O, Brox J, Cedraschi C, et al; On behalf of the COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006 Mar;15(Supplement 2):s192-s300. 2. American Medical Association. Current Procedural Terminology: CPT 2008, Professional Edition. AMA Press, 2007. 3. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008. Accessed 10/1/08. 4. Barnsley L, Lord S, Wallis S, Bogduk N. False positive rates of cervical zygapophysial joint blocks. Clin J Pain 1993;9:124-30. 5. Bogduk N. A narrative review of intra-articular corticosteroid injections for low back pain. Pain Med. 2005 Jul-Aug;6(4):287-96. 6. Boswell M, Colson J, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007;10:229-53. 7. Boswell M, Colson J, Spillane W. Therapeutic Facet Joint Interventions in Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications. Pain Physician 2005;8:101-114. 8. Boswell M, Shah R, Everett Cet al. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician. 2005 Jan;8(1):1-47. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 6 of 10

9. Boswell M, Trescot A, Datta S, et al; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan;10(1):7-111. 10. Bough B, Thakore J, Davies M, Dowling F. Degeneration of the lumbar facet joints. Arthrography and pathology. J Bone Joint Surg Br 1990; 72: 275-6. 11. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991 Oct 3;325(14):1002-7. 12. Carrera G. Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology 1980; 137: 665-7. 13. Carrera G, Williams A. Current concepts in evaluation of the lumbar facet joints. Crit Rev Diagn Imaging 1984; 21: 85-104. 14. Cohen S, Raja S. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007;106:591-614. 15. Destouet J, Gilula L, Murphy W, Monsees B. Lumbar facet joint injection: indication, technique, clinical correlation, and preliminary results. Radiology 1982; 145: 321-5. 16. Dreyfuss P, Dreyer S. NASS. Lumbar zygapophysial (facet) joint injections. Spine J. 2003 May- Jun;3(3 Suppl):50S-59S. 17. Eisenstein S Parry C. The lumbar facet arthrosis syndrome--clinical presentation and articular surface changes. J Bone Joint Surg Br 1987; 69: 3-7. 18. Fairbank J, Park W, McCall I, O'Brien J. Apophyseal injection of local anesthetic as a diagnostic aid in primary low-back pain syndromes. Spine 1981; 6: 598-605. 19. Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. 2007 Jul 15;32(16):1754-60. 20. Friedrich K, Nemec S, Peloschek P, et al. The prevalence of lumbar facet joint edema in patients with low back pain. Skeletal Radiol. 2007 Aug;36(8):755-60. Epub 2007 Apr 5. 21. Fritz J, Niemeyer T, Clasen S, et al. Management of chronic low back pain: rationales, principles, and targets of imaging-guided spinal injections. Radiographics. 2007 Nov-Dec;27(6):1751-71. 22. Fuchs S, Erbe T, Fischer H, Tibesku C. Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine. J Vasc Interv Radiol. 2005;16:1493-8. 23. Hancock M, Maher C, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 Oct;16(10):1539-50. Epub 2007 Jun 14. 24. Helbig T, Lee C. The lumbar facet syndrome. Spine 1988; 13: 61-4. 25. Jackson R, Jacobs R, Montesano P. Facet joint injection in low-back pain: a prospective statistical study. Spine 1988; 13: 966-71. 26. Jackson R. The facet syndrome. Myth or reality? Clin Orthop 1992; 279: 110-21. 27. Jajic I, Jajic Z: The prevalence of osteoarthrosis of the sacroiliac joints in an urban population. Clin Rheumatol 1987; 6: 39 41 28. Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil. 2008 Apr;89(4):770-4. 29. Korner-Bitensky N, Wood-Dauphinee S, Siemiatycki J, et al: Health related information post discharge: telephone versus face to face interviewing. Arch Phys Med Rehabil 1994; 75: 1287 96. 30. Laslett M, McDonald B, Aprill C, et al. Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Spine J. 2006 Jul-Aug;6(4):370-9. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 7 of 10

31. Laslett M, Oberg B, Aprill C, McDonald B. Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test. BMC Musculoskelet Disord. 2004 Nov 16;5:43. 32. Lau L, Littlejohn G, Miller M. Clinical evaluation of intra-articular injections for lumbar facet joint pain. Med J Aust 1985; 143: 563-5. 33. Lewinnek G, Warfield C. Facet joint degeneration as a cause of low back pain. Clin Orthop 1986; 213: 216-22. 34. Lilius G, Harilainen A, Laasonen E, Myllynen P. Chronic unilateral low-back pain. Predictors of outcome of facet joint injections. Spine 1990; 15: 780-2. 35. Lilius G, Laasonen E, Myllynen P, et al. Lumbar facet joint syndrome. A randomised clinical trial. J Bone Joint Surg Br 1989;71:681-4. 36. Lippitt A. The facet joint and its role in spine pain. Management with facet joint injections. Spine 1984; 9: 746-50. 37. Magora A, Schwartz A. Relation between the low back pain syndrome and X-Ray findings. I. Degenerative osteoarthritis. Scand J Rehab Med 1976; 8: 115-25. 38. Manchikanti L, Cash K, Pampati V, Fellows B. Influence of psychological variables on the diagnosis of facet joint involvement in chronic spinal pain. Pain Physician. 2008 Mar- Apr;11(2):145-60. 39. Manchikanti L, Damron K, Cash K, et al. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial. Pain Physician. 2006 Oct;9(4):333-46. 40. Manchikanti L, Manchikanti K, Cash K, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician. 2008 Jan;11(1):67-75. 41. Manchikanti L, Manchikanti K, Manchukonda R, et al. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, doubleblind controlled trial. Pain Physician. 2007 May;10(3):425-40. 42. Manchikanti L, Manchukonda R, Pampati V, et al. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007 Apr;88(4):449-55. 43. Manchikanti L, Singh V, Falco F, et al. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial. Pain Physician. 2008 Mar-Apr;11(2):121-32. 44. Manchukonda R, Manchikanti K, Cash K, et al. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007 Oct;20(7):539-45. 45. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain 1989; 39: 37-40. 46. Marks R, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Pain 1992;49:325-8. 47. McCall IW, Park W, O'Brien J. Induced pain referral from posterior lumbar elements in normal subjects. Spine 1979; 4: 441-6. 48. Mooney V, Robertson J. The facet syndrome. Clin Orthop 1976; 115: 149-56. 49. Moran R, O'Connell D, Walsh M. The diagnostic value of facet joint injections. Spine 1988; 13: 1407-10. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 8 of 10

50. Murtagh F. Computed tomography and fluoroscopy guided anesthesia and steroid injection in facet syndrome. Spine 1988; 13: 686-9. 51. Nelemans P, de Bie R, de Vet H, Sturmans F, Injection therapy for subacute and chronic benign low back pain, Cochrane Database Syst Rev 2000;(2):CD001824. 52. Nordin M, Carragee E, Hurwitz L, et al; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S153-69. 53. Raymond J, Dumas J. Intraarticular facet block: diagnostic test or therapeutic procedure? Radiology 1984; 151: 333-6. 54. Resnick D, Choudhri T, Dailey A, et al; American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2005 Jun;2(6):707-15. 55. Revel M, Listrat V, Chevalier X, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil 1992; 73: 824-8. 56. Revel M, Poiraudeau S, Auleley G, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998 Sep 15;23(18):1972-6. 57. Schwarzer A, Aprill C, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints: Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: 1132-7. 58. Schwarzer A, Aprill C, Derby R, et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994; 58: 195-200. 59. Schwarzer A, Wang S, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: A study in an Australian population with chronic low back pain. Ann Rheum Dis 1995;54:100-6. 60. Schwarzer A, Wang S, O'Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 20(8):907-12, 1995 Apr 15. 61. Sehgal N, Dunbar E, Shah R, Colson J. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician. 2007 Jan;10(1):213-28. 62. Slipman C, Bhat A, Gilchrist Ret al, A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain, Spine J. 2003 Jul- Aug;3(4):310-6. 63. van Tulder M, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J. 2006 Jan;15 Suppl 1:S82-92. Epub 2005 Dec 1. 64. Woodward J, Weinstein S: Epidural injections for the diagnosis and management of axial and radicular pain syndromes. Phys Med and Rehab Clin North Amer. Injection techniques. Principles Practice 1995; 6: 691 714. 65. Workloss Data Institute. Official Disability Guidelines. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 9 of 10

66. Young S, April C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003 Nov-Dec;3(6):460-5. V2.0; Effective: 11-14-2014 Facet Joint Injections-Medical Branch Blocks RETURN Page 10 of 10