DESCRIPTION
The purpose of a lumbar epidural steroid injection is to achieve relief from nerve root irritation (i.e., radicular pain or sciatica) related to encroachment by bone or disk herniation, or by various causes of neuritis (e.g., radiation, chemical or autoimmune). The techniques are most accurately performed using fluoroscopy visualization for needle placement. The procedure may generally be safely performed in the outpatient setting. There are three basic techniques for lumbar epidural steroid injections:
Caudal (injection into the lower epidural space)
Translumbar (injection into a higher lumbar epidural space)
Transforaminal (injection along the desired nerve root)
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 an 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 epidural 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 Facet Steroid Injections for Treatment of Low Back Pain
MEDICAL APPROPRIATENESS
Lumbar epidural 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
There is documentation of radiculopathy (by exam, imaging, or neuro-testing) which is unresponsive to conservative treatment (e.g., oral medications, rest/limited activity, and/or physical therapy)
ABSENCE of ALL of the following:
Allergy to the medication to be administered
A significantly altered or eliminated epidural space (e.g., congenital anatomic anomalies or previous surgery)
Anticoagulation therapy
Bleeding disorder
Clinically significant spinal stenosis
Localized infection in the region to be injected
Systemic infection
Other co-morbidities which could be exacerbated by steroid usage (e.g., poorly controlled hypertension, severe congestive heart failure, diabetes, etc.)
More than 3 (three) epidural steroid injections have been given without significant relief of low back pain over a reasonable length of time
IMPORTANT REMINDER
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
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.
Abdi, S., Datta, S., Trescot, A. M., Schultz, D. M., Adlaka, R., Atluri, S. L., et al. (2007). Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician, 10 (1), 185-212. (Level 1 Evidence - Independent study)
American Academy of Neurology. (2007). Use of epidural steroid injections to treat radicular lumbosacral pain. Retrieved February 11, 2009 from http://www.aan.com/practice/guideline/uploads/250.pdf.
American Society of Anesthesiologists. (1997). Practice guidelines for chronic pain management. Retrieved February 11, 2009 from http://www.asahq.org/publicationsAndServices/ChronicPainMgmt.pdf.
Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., et al. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44 (11), 1399-1406. (Level 1 Evidence - Industry sponsored)
Armon, C., Argoff, C., E., Samuels, J., & Backonja, M. M. (2007). Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 68 (10), 723-729.
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.
Dashfield, A. K., Taylor, M. B., Cleaver, J. S., & Farrow, D. (2005). Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: A prospective, randomized, double-blind trial. British Journal of Anaesthesia, 94 (4), 514-519. (Level 1 Evidence - Independent study)
Hayes. Medical Technology Directory. (2007, October). Epidural steroid injections for low back pain and sciatica. Retrieved February 10, 2009 from www.Hayesinc.com/subscribers. (55 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., Cash, K. A., McManus, C. D., Pampati, V., & Smith, H. S. (2008). Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 1 - Discogenic pain without disc herniation or radiculitis. Pain Physician, 11 (6), 785-800. (Level 1 Evidence - Independent study)
Manchikanti, L., Singh, V., Cash, K. A., Pampati, V., & Datta, S. (2008). Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3 - Post surgery syndrome. Pain Physician, 11 (6), 817-831. (Level 1 Evidence - Independent study)
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.
Southern, D., Lutz, G. E., Cooper, G., & Barre, L. (2003). Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain? Pain Physician, 6 (2), 167-172. (Level 1 Evidence - Independent study)
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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