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 treatment of acute and chronic low back pain is considered medically appropriate if ALL of the following criteria are met:
When performed under fluoroscopy
Used as a diagnostic trial to determine the origin of the pain
Used 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) and when 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.).
ADDITIONAL INFORMATION
In order to minimize the risks from large doses of steroids, more than 4 (four) injections within a 12-month period is not generally appropriate.
SOURCES
109th Congress: 1st Session: H. R. 1020: (2005, March). National pain care policy act of 2005 (introduced in House). Retrieved March 23, 2006 from http://thomas.loc.gov.
American Society of Anesthesiologists. (1997). Practice guidelines for chronic pain management. Retrieved February 11, 2009 from http://www.asahq.org/publicationsAndServices/ChronicPainMgmt.pdf.
BlueCross BlueShield of Tennessee network physicians. September 2001.
Boswell, M. V., Trescot, A. M., Datta, S., Schultz, D. M., Hansen, H. C., Abdi, S., et al. (2007). Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician, 10 (1), 7-111.
Hayes. Medical Technology Directory. (2006, October). Facet blocks for chronic back pain. Retrieved February 10, 2009 from www.Hayesinc.com/subscribers. (48 articles and/or guidelines reviewed)
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.
International Spinal Injection Society. Standards for the performance of spinal injection procedures. Part 1: Zygapophysial joint blocks. Retrieved September 14, 2001 from http://www.spinalinjection.com/ISISI/standard.stand1.htm.
Lavelle, W. F., Lavelle, E. D., & Smith, H. S. (2008). Interventional techniques for back pain. Clinics in Geriatric Medicine, 24 (2), 345-368.
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., Singh, V., Falco, F. J., Cash, K. A., & Pampati, V. (2008). Effectiveness of thoracic medial branch blocks in managing chronic pain: A preliminary report of a randomized, double-blind controlled trial: Clinical Trial NCT00355706. Pain Physician, 11 (4), 491-504. (Level 1 Evidence - Independent study)
National Guideline Clearinghouse. (2005, August). Guideline on diagnostic facet medial nerve branch blocks and facet neurotomy. Retrieved March 23, 2006 from http://www.guidelines.gov.
National Guideline Clearinghouse. (2005, June). Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion. Retrieved February 10, 2009 from http://www.guidelines.gov.
National Guideline Clearinghouse. (2007, January). Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Retrieved February 10, 2009 from http://www.guidelines.gov.
National Guideline Clearinghouse. (2007, June). Low back - lumbar & thoracic (acute & chronic). Retrieved February 10, 2009 from http://www.guidelines.gov.
ORIGINAL EFFECTIVE DATE: 4/1999
MOST RECENT REVIEW DATE: 3/12/2009
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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