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DESCRIPTIONEpidural steroid injections are administered to patients suffering from back pain and sciatica to relieve local inflammation, alleviate symptoms and promote resumption of activities of daily living. The procedure is employed as an intermediate alternative to surgery in selected cases.
Clinical indications are radicular (radiating) back or neck pain. Please note that the presence of radicular pain is a requirement for epidural steroid injections. Other less defined uses include lumbalgia, lumbar or cervical strain, vertebral compression fractures and pain due to spinal stenosis, spondylosis, pars defects and degenerative disc disease. Use for any diagnosis except lumbar or cervical radiculopathy and spinal stenosis is controversial and poorly supported by the literature.
POLICYEpidural steroid injections may be considered medically necessary as treatment of cervical or lumbar radiculopathy.
Under any and all circumstances, reimbursement will be limited to a series of three (3) injections in a calendar year at any one level. Separate billing for the drug injected is not allowed. This is included in the administration of the injection.
If there is no documented pain relief after two injections; no further injection will be considered medically necessary at this level.
If the first two (2) injections are done WITHOUT fluoroscopic imaging and they have failed to provide documented pain relief, then a third injection must be by fluoroscopic guidance.
POLICY EXCEPTIONSWhen practitioners use a transforamenal technique, there may be more than one epidural injection in the same block session. This should not count as more than one injection in the series, but additional epidural injections on the same day are reimbursed decrementally as additional procedures.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
A separate reimbursement will not be provided for monitored anesthesia care during any of the above approved procedures.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY8/1997: Approved by Medical Policy Advisory Committee (MPAC)
11/2000: Revised by MPAC, Epidural injections limitation specified "at any one level" "If there is no documented pain relief (of at least three-month duration) after two injections; no further injection will be considered medically necessary at this level." added, Selective dorsal rhizotomy (63185-63190) changed from investigational to medically necessary for diplegic and quadriplegic spasticity, Percutaneous Lumbar Discectomy (62287) remains investigational
6/15/2001: Policy Guidelines references to inappropriately used codes “There is no specific CPT code identifying the non-covered epidural adhesiolysis procedure. The following CPT codes have been inappropriately used: 62281 Injection of neurolytic substance; epidural, cervical or thoracic, 62282 Injection of neurolytic substance; epidural, lumbar, or caudal.” deleted, Code Reference section updated, CPT code 72275 added covered codes, CPT code 62263, 76003 added non-covered codes
7/3/2001: Code Reference section updated, ICD-9 procedure code 04.2, 05.32 with note “This is only covered in extremely rare circumstances as a last resort” added covered codes, ICD-9 procedure code 03.6 added non-covered codes, ICD-9 diagnosis statement “all other diagnosis not listed above” added non-covered codes
11/16/2001: Selective Rhizotomy (63185-63190) and Percutaneous Lumbar Discectomy (62287) addressed in separate policies. CPT code range 64600-64680 and associated ICD-9 diagnosis and procedure codes moved from Policy Exceptions to the covered table under the "Code Reference" section.
2/14/2002: Investigational definition added
2/28/2002: Managed Care Requirements section “Prior authorization and referral to a specialist are required for the Primary Care Health Plan” deleted
4/26/2002: Type of Service and Place of Service deleted
1/22/2003: CPT code range 64600-64680 listed individually
3/3/2003: Code Reference section updated, CPT code 0027T, 62264 added non-covered codes, CPT code 62263 description revised non-covered codes
11/12/2003: Code Reference section updated, CPT codes 62275, 62278, 62289, 62298 deleted, ICD-9 procedure code 99.23 deleted, ICD-9 diagnoses 723.4 and 724.2 listed separately and description revised, ICD-9 diagnosis code range 724.0-724.09 listed separately
1/7/2004: The following note added to CPT code 72275 and 76005 "Code 72275 includes code 76005. When both an epidurography and a fluoroscopy are performed during the same session, only code 72275 should be billed."
4/26/2004: CPT code 64681 added to Policy Exceptions and Code Reference section
7/15/2004: Reviewed by MPAC, "Reimbursement will be limited to a series of three (3) injections once in a nine (9) month period at any one level." changed to "Reimbursement will be limited to a series of three (3) injections in a calendar year at any one level." this change is effective November 1, 2004, Epidural Adhesiolysis remains investigational, Sources updated.
8/11/2004: Code Reference section reviewed, no changes.
10/1/2004: Code Reference section reviewed, no changes.
10/8/2004: Prior authorization “Beyond the treatment limits specified, prior approval is required. Medical review for prior approval will include individual consideration of: 1) All medical records 2) Appropriate specialty provider 3) Second opinion, optional.” deleted, CPT code 64622, 64623, 64626, 64627 deleted from covered codes, See Facet Blocks for Treatment of Back Pain medical policy for CPT codes 64622-64627.
3/31/2005: Pain Management Subcommittee revisions reviewed by MPAC and approved, "If the first two (2) injections are done WITHOUT fluoroscopic imaging and they have failed to provide documented pain relief, then a third injection must be by fluoroscopic guidance." added Policy section, clarification of "Reimbursement will be limited to a series of three (3) injections in a calendar year at any one level. Separate billing for the drug injection is not allowed. This is included in the administration of the injection." to be "under any and all circumstances" added Policy section, this policy change is effective June 1, 2005.
5/6/2005: “CPT-4 codes 64600 - 64681, nerve destruction by a neurolytic agent, are not covered, except in the extremely rare circumstance as a last resort. (added 64681 4/26/2004) (See Facet Blocks for Treatment of Back Pain medical policy for CPT codes 64622-64627)” deleted Policy Exceptions, Code Reference section reviewed, CPT code 64600, 64605, 64610, 64612, 64613, 64614, 64620, 64630, 64640, 64680, 64681 deleted, ICD-9 procedure code 04.2, 05.32 deleted covered codes.
5/31/2006: Policy updated. ( three-month duration requirement removed from policy)
10/3/2006: Policy updated. CPT codes 0027T, 62263, 62264, 76003 and ICD-9 procedure code 03.6 deleted from policy.
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions.
11/24/2009: Coding Section updated to include ICD9 diagnosis code 722.52 to covered codes table, removed deleted CPT4 code 76005 from covered codes table.
10/14/2010: Annual ICD-9 code update: Revised the description of 724.02 and added new ICD-9 code 724.03.
10/30/2013: Added the following to the policy statement: Epidural steroid injections may be considered medically necessary as treatment of cervical or lumbar radiculopathy. Existing policy statement unchanged but reordered for clarity purposes.
08/25/2015: Code Reference section updated to add ICD-10 codes. Removed CPT code 77003. Updated the code descriptions for 62310, 62311, 64479, 64480, 64483, and 64484.
06/06/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)Review of medical policy related to epidural steroid injections from Blue Cross Blue Shield plans nationally.
Literature search through Grateful Med and MEDLINE databases focused on references containing the Medical Subject heading of: lumbar epidural steroid injections, periradicular injections, lumbar disc herniation, radiculopathy, herniated nucleus pulposus, sciatica, degenerative disc disease, facet syndrome, spinal stenosis, spondylolysis, spondylolisthesis, cortisone, steroids, triamcinolone, methylprednisolone acetate, lidocaine hydrochloride, procaine hydrochloride, bupivacaine hydrochloride, betamethasone, Depomedrol-40.
Hayes Medical Technology Directory
Laxmaiah Manchikanti, MD et al. (in press). One day lumbar epidural Adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized controlled study. Pain Physician. (added 7-15-2004)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is perforemd according to the "Policy" section of this document.