BlueCross BlueShield of Tennessee Medical Policy Manual

Lumbar Facet Steroid Injections for Treatment of Low Back Pain

DESCRIPTION

Lumbar facet injections for the treatment of low back pain involve a steroid medication being injected into the facet joint (intra-articular) or around the nerve supply to the facet joint (medial branch block) of the lumbar spine. The diagnostic objective is to help determine the origin of the low back pain. The therapeutic objective is temporary relief of low back pain unresponsive to conservative treatment (e.g., oral medications, rest/limited activity, and/or physical therapy). These techniques use fluoroscopy visualization for needle placement. The procedure is performed in the outpatient setting.

The scientific literature does not reveal a consensus of definition for acute and chronic low back pain. The following definitions will be used for the purpose of this policy:

• Acute low back pain is pain that resolves during the expected healing time of a low back injury or illness, usually considered to be 6 months or less.

• Chronic low back pain is pain that persists beyond the expected healing time of a low back injury or illness, usually considered to be beyond 6 months.

It is also recognized that acute exacerbations or new acute episodes may be superimposed on otherwise chronic conditions.

POLICY

• Lumbar facet steroid injections for the treatment of acute and chronic low back pain is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Policies with similar titles: Lumbar Epidural Steroid Injections for Treatment of Low Back Pain

MEDICAL APPROPRIATENESS

• Lumbar facet steroid injections for the management of acute and chronic low back pain is considered medically appropriate if ALL of the following criteria are met:

• • When performed under fluoroscopy for ANY ONE of the following:

  • • As a diagnostic trial to determine the origin of the pain

    • As a therapeutic injection when temporary relief of low back pain is determined to be clinically appropriate (e.g. to participate in physical therapy or essential activities of daily living)

  • Conservative treatment has failed (e.g., oral medications, rest/limited activity, and/or physical therapy)

  • ABSENCE of ALL of the following:

  • • Allergy to the medication to be administered

    • Anticoagulation therapy

    • Bleeding disorder

    • Localized infection in the region to be injected

    • Systemic infection

    • Other co-morbidities that could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)

IMPORTANT REMINDERS

• Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

• We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

In order to minimize the risks from large doses of steroids, more than 4 (four) injection sessions within a 12-month period is not generally appropriate.

SOURCES

BlueCross BlueShield of Tennessee network physicians. September 2001.

Heran, M., Smith, A. D., & Legiehn, G. M. (2008). Spinal injection procedures: A review of concepts, controversies, and complications. Radiologic Clinics of North America, 46 (3), 487-514.

Manchikanti, L., Boswell, M., Singh, V., Benyamin, R., Fellows, B., Abdi, S., et al. (2009) Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12 (4), 699-802.

Manchikanti, L., Manchikanti, K. N., Manchukonda, R., Cash, K. A., Damron, K. S., Pampati, V., et al. (2007). Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: Preliminary report of a randomized, double-blind controlled trial: Clinical Trial NCT00355914. Pain Physician, 10 (3), 425-440. (Level 1 Evidence - Independent study)

Manchikanti, L., Singh, V., Falco, F. J., Cash, K. A., & Pampati, V. (2008). Lumbar facet joint nerve blocks in managing chronic facet joint pain: One-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914. Pain Physician, 11 (2), 121-132. (Level 1 Evidence - Independent study)

Peh, W. (2011). Image-guided facet joint injection. Biomedical Imaging and Intervention Journal, 7 (1).

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. (2010). Anesthesiology, 112 (4), 810-833.

Winifred S. Hayes. Medical Technology Directory. (2006, October, Last updated search 2010). Facet blocks for chronic back pain. Retrieved October 31, 2011 from www.Hayesinc.com/subscribers. (48 articles and/or guidelines reviewed)

Work Loss Data Insitute. (2008). Low back - lumbar & thoracic (acute & chronic). Retrieved October 31, 2011 from http://www.guidelines.gov.

ORIGINAL EFFECTIVE DATE:  4/1999  

MOST RECENT REVIEW DATE:  1/12/2012

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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