Spinal Injections

Coverage decision

Therapeutic medial branch nerve block injections, facet joint injection, and intradiscal injections are not covered services. These injections may be covered diagnostically on a very limited basis.

Therapeutic/diagnostic epidural injections and sacroiliac joint injections are covered services for State Fund, Self-Insured and Crime Victims claims, when the following criteria are met:

The patient has an allowed spine condition, AND one of the following:

    • Radicular pain (pain radiating down the leg or arm)
    • Radiculopathy, with documented objective findings such as:
      • Motor weakness
      • Dermatomal sensory loss
      • Reflex asymmetry or loss
      • A positive diagnostic selective nerve root block, which is: single-level, low-volume, steroid-free, includes a post block pain diary and possible placebo injection in the series
    • Sacroiliac joint pain

For clarification and billing details, refer to the chart at the bottom of this page (see Billing and payment information).

Epidural injections in the cervical, thoracic or lumbar spine (ESI):

  1. Injured worker's level of function and pain must be clearly documented on a validated instrument at baseline prior to treatment and before each injection (no more than 2 weeks before the injection)
  2. Injured worker must have an allowed spine condition
  3. The allowed condition must be consistent with a finding of radicular pain or radiculopathy
  4. If only radicular pain is present, (with or without positive straight leg raise testing) there must be a failure of at least 4 weeks of conservative therapy* (see definition of conservative therapy)
  5. When objective evidence of radiculopathy is documented, there must be a failure of at least 2 weeks of conservative therapy
  6. Fluoroscopic, CT or ultrasound guidance must be utilized
  7. Restrictions:
  • No more than 2 injections (2 dates of service) can be given without documented improvement in function and pain of at least 30%; compared to the baseline documented before the commencement of injections. Function and pain must be measured and documented on a validated instrument (see below and example of a validated scale that measures clinically meaningful improvement)

    Patients experiencing clinically meaningful improvement in pain and function measured objectively should exhibit, and clinician should document:

    • A significant reduction in pain produced by the most recent epidural steroid injection compared to the pre-injection pain level.
    • A significant improvement in function produced by the most recent epidural steroid injection compared to the pre-injection level of function. Such improvement in function can be observed in many different ways, and will likely vary patient to patient. Some examples of activities that lend themselves to objectively measurement and quantification include:
      • Sustained, progressive improvement in strength, stamina or agility
      • Sustained participation in work-hardening or work conditioning programs
      • Sustained participation in the vocational retraining phase of vocational rehabilitation process.
    • No more than 3 injections within 6 months with at least 6 weeks between each injection
    • Maximum number of injections: 4 per 365-day period
    • Maintenance ESI (i.e., treatment for longer than 365 days since the first injection) is not covered because long term therapeutic effect and long term safety of ESI have not been established. The only exception is if 30% or more clinically meaningful improvement in pain and function on a validated instrument (see example of a validated scale that measures clinically meaningful improvement) AND any one of the following are achieved and documented:
      • Sustained, progressive improvement in strength, stamina or agility
      • Sustained participation in work-hardening or work conditioning programs
      • Sustained participation in the vocational retraining phase of vocational rehabilitation process
      • Return to work
    • No more than 2 levels and one side per date of service
    • MRI is not a prerequisite for performance of ESI.

Sacroiliac joint injections

  1. Patient has an allowed condition that includes sacroiliac joint pain.
  2. Failure of at least 6 weeks of conservative therapy.
  3. Must be done with fluoroscopic or CT guidance.
  4. Restrictions:
    • No more than 1 injection without documented improvement in function and pain of at least 30%, compared to the baseline documented before the commencement of injections.+ Requests for more than 2 injections require clinical review.

Facet injections and medial branch blocks

These injections are used on a diagnostic basis only, to determine whether the patient is a candidate for a facet neurotomy:

  • There must be failure of at least 6 months of conservative therapy,
  • Patient must have the clinical findings and diagnostic tests outlined in the facet neurotomy guideline,
  • Reference the facet neurotomy guideline, before planning a facet injection or medial branch block,
  • Restrictions: see facet neurotomy guideline for details.

Note: CPT codes are the same regardless of the purpose of these injections; only diagnostic are covered.

Intradiscal injections

Not covered for the assessment of chronic low back pain or lumbar degenerative disc disease; for other conditions, see coverage decision on discography.

*Definition of conservative therapy: Conservative therapy includes evidence-based treatments that have been demonstrated to be of use in the management of low back or neck pain; such as physical therapy or graded exercise, massage, medications, etc.

For a reference on conservative treatment of low back pain, see: Chou R, Quaseem A, Snow V, Casey D, Cross TJ, Shekelle P and Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine 2007; 147:478-491.

+Measuring clinically meaningful improvement: While there is no universally accepted tool to assess a worker's function and pain, the Washington State Agency Medical Directors' Group (AMDG), in its opioid dosing guideline, recommends the use of the Two-Item Graded Chronic Pain Scale (below). This is a quick, two-question tool to track both function and pain when administered regularly during a patient's treatment. Other functional assessment tools that are well validated and disease-specific may also be used to assess the worker's physical functioning. If a disease-specific tool is used, each tool will have its own definition for clinically meaningful improvement. Examples of meaningful improvement include resumption of physical activities and activities of daily living, improved work capacity, and/or the ability to progress in vocational retraining. 

An example of a validated scale that measures function and pain:

Standard Questions: Pain interference and intensity

1. In the last month, how much has pain interfered with your daily activities? Use a scale from 0 to 10, where 0 is “no interference” and 10 is “unable to carry on any activities.”

No
interference
Unable to carry on
any activities
0 1 2 3 4 5 6 7 8 9 10

2. In the last month, on average, how would you rate your pain? Use a scale from 0 to 10, where 0 is “no pain” and 10 is “pain as bad as it could be.” (That is, your usual pain at times you were in pain)

No
pain
Pain as bad as
it could be
0 1 2 3 4 5 6 7 8 9 10

The link for the opioid guideline: http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf

The following are NOT included in this coverage decision:

  • Sympathetic blocks.
  • Trigger point injections.
  • Dry needling.
  • Hyaluronic acid injections.
  • Adhesiolysis.
  • Intraarticular injections.
  • Botulinum toxins.
  • Occipital nerve root blocks.

Background policy information

On March 18, 2011, the State Health Technology Clinical Committee (HTCC) met at an open public meeting to determine whether state agencies should pay for spinal injections. Based on a review of the best available evidence of safety, efficacy and cost-effectiveness, the committee decided to cover spinal injections with certain limitations. The decision was made final by the HTCC on June 17, 2011.

Complete information on this HTCC determination is available at: http://www.hta.hca.wa.gov/spinal_injections.html

All requests for spinal injections require prior authorization

How to request authorization for spinal injections:

For State Fund Claims

All requests are reviewed by L&I's utilization review (UR) vendor (Qualis). To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact Qualis Health in any of the following ways:

For Crime Victims

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact the Crime Victims' Compensation Program's Claim Manager by:

  • Phone: 800-762-3716 (toll free)
  • Fax: 360-902-5333

Additional information is available at: www.CrimeVictims.Lni.wa.gov.

For Self-Insured Claims:

Contact the self-insured employer (SIE) or their third party administrator (TPA) to request authorization. For a list of SIE/TPAs, go to:

http://lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

Billing and payment information

Providers should add the prior authorization number to their bill.

Codes Injection Type Therapeutic Diagnostic
62310     64483
62311     64484
62318     0228T
62319     0229T
64479     0230T
64480     0231T
Epidural Injections
Cervical, Thoracic or Lumbar
Covered, with conditions and utilization review Covered, with conditions and utilization review
27096 Sacroiliac Joint Injections Covered, with conditions and utilization review Not covered
64490     0213T
64491     0214T
64492     0215T
64493     0216T
64494     0217T
64495     0218T
Facet Injections
Medial Branch Blocks
Not covered
Not covered
Covered with conditions; Candidates for facet neurotomy
N/A Intradiscal Not covered Not covered

 


For more information:
Teresa Cooper, RN, ONC
360-902-5762
Teresa.Cooper@lni.wa.gov

 

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