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 therapeutic objective is temporary relief of low back pain unresponsive to conservative treatment (e.g., oral medications, rest/limited activity, and/or physical therapy). This diagnostic procedure uses fluoroscopy visualization for needle placement. This 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:

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

POLICY

See also:  MCG Care Guideline - Facet Neurotomy

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

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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

Agency for Healthcare Research and Quality (2013, March) Pain management injection therapies for low back pain – Project ID ESIB0813. Retrieved January 5, 2016 from: http://www.ahrq.gov.

American College of Radiology. (2011) ACR Appropriateness criteria® low back pain. Retrieved January 5, 2016 from: http://www.guideline.gov. (NCG#008863)

American Pain Society (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American college of physicians and the American pain society. Retrieved January 5, 2016 from: http://annals.org.

BlueCross BlueShield of Tennessee network physicians. September 2001.

Center for Medicare and Medicaid Services. CMS.gov. (2015, October) Local Coverage Determination (LCD) Surgery: Lumbar facet blockade (L34293). Retrieved January 5, 2015 from: https://www.cms.gov/.

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)

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R., Boswell, M., Buenaventura, R., et. al. (2013) An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician 2013; 16:S49-S283.

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.

UpToDate®. (2015. December) Subacute and chronic low back pain: nonsurgical interventional treatment. Received January 5, 2016 from: www.uptodate.com. (65 articles and/or guidelines reviewed)

Work Loss Data Institute. (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:  2/25/2016

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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