Clinical UM Guideline


Subject:Pain Management: Cervical, Thoracic & Lumbar Facet Injections
Guideline #:  CG-SURG-32Current Effective Date:  01/14/2014
Status:Revised Last Review Date:  11/14/2013

Description

This guideline addresses facet blocks in the lower back (lumbar spine), mid back (thoracic spine) and neck (cervical spine). Facet joint injections (FJI) for painful axial spinal conditions can be done for both diagnostic and therapeutic reasons.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary: 

Facet (cervical, thoracic, lumbar) injections are considered medically necessary when all of the criteria below are met:

  1. The individual has back pain which has not responded to 3 months of appropriate conservative therapy*; AND
  2. The pain is interfering with functional activities; AND
  3. The pain is not radicular; AND
  4. The pain is exacerbated by extension and prolonged standing/sitting and is relieved by rest; AND
  5. The individual has not had a vertebral fusion at the levels proposed for treatment; AND
  6. There is no unexplained neurological deficit; AND
  7. There is no history of coagulopathy, systemic infection, local infection, or unstable medical conditions; AND
  8. The facet block meets criteria for one of the injections below:
    1. The injection is being performed to diagnose the facet joint as the source of the individual's pain;
      OR
    2. The injection is being performed to treat pain when all of the following criteria are met:
      1. A diagnostic block provided pain relief (at least 50% pain relief with the ability to perform previously painful maneuvers); AND
      2. A series of injections at that spinal region begin no sooner than one week after a successful diagnostic block; AND
      3. The injections continue no more often than every 2 months with a maximum of six injections per spinal region per year.

*Note: Conservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual's specific presentation, physical findings and imaging results.

Note: If therapeutic facet injections are to be performed at a different spinal region, a positive diagnostic block is required in that region and the therapeutic frequency is limited to every 2 months for that region and therapeutic improvement is required in that region for additional facet injections. 

Not Medically Necessary:

Facet injections of the spine are considered not medically necessary when the criteria specified above are not met, or when any of the following contraindications is present:

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

CPT 
64490-64492Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic [includes codes 64490, 64491, 64492]
64493-64495Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral [includes codes 64493, 64494, 64495]
0213T-0215TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic [includes codes 0213T, 0214T, 0215T]
0216T-0218TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral [includes codes 0216T, 0217T, 0218T]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
723.1Cervicalgia
723.2Cervicocranial syndrome
723.8Other syndromes affecting cervical region
724.1Pain in thoracic spine
724.2Lumbago
724.3Sciatica
724.5Backache, unspecified
  
ICD-10 Diagnosis[For dates of service on or after10/01/2014]
M54.2Cervicalgia
M54.30-M54.31Sciatica
M54.40-M54.42Lumbago with sciatica
M54.5Low back pain
M54.6Pain in thoracic spine
M54.89Other dorsalgia
M54.9Dorsalgia, unspecified
  
Discussion/General Information

Facet injections, in the cervical, thoracic and lumbar regions of the spine, are divided into two phases: The diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. If there is no pain relief after the diagnostic injection (negative block), the therapy is not continued. There are no historical, physical or imaging studies that are diagnostic of facet joint pain. The diagnosis is one of exclusion that is facilitated by performing a diagnostic block of the facet joint or nerves (medial branch of the posterior primary ramus) innervating the joints.

Acute pain caused by injury, surgery or illness generally lasts for a short period of time, and usually disappears when the underlying cause has been treated or has healed. Chronic pain persists even when the initial cause (injury, disease) has resolved. The intensity will vary from mild to severe disabling pain that may significantly reduce quality of life.

Facet injections (intraarticular injections and medial branch blocks) are used to treat chronic back pain from facet joint origin, using anesthetic agents with or without or steroids. A facet block is an injection into or around the synovial joints formed by the facets on the articular processes of contiguous vertebrae.

The ASA (1997) has stated that the goals of pain management are to:

In 2009 Manchikanti and colleagues issued updated comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. The guideline recommendations diagnostic facet joint nerve block for individuals with pain that has lasted at least 3 months with failure to respond to conservative therapy, including chiropractic care, physical therapy modalities with exercises, and non-steroidal anti-inflammatory agents.

In a 2008 update of the Cochrane Database Systematic Review, Staal and associates stated that the effectiveness of injection therapy for low-back pain is still debatable. Heterogeneity of target tissue, pharmacological agent and dosage generally found in randomized controlled trials (RCTs) points to the need for clinically valid comparisons in a literature synthesis. However, it cannot be ruled out that specific subgroups of individuals may respond to a specific type of injection therapy.

Chou and colleagues (2009) evaluated clinical data for the American Pain Society Clinical Practice Guideline: Nonsurgical Interventional Therapies for Low Back Pain. They found that evidence from randomized, placebo controlled trials showing benefits of most interventional injection therapies for back pain is limited. More evidence is needed to demonstrate efficacy of injection therapies that target presumed facet joint or sacroiliac joint pain. For radiculopathy, there is fair evidence of benefits associated with epidural steroid injections however; the decision to use epidural steroid injection should take into account the short-term nature of symptom relief and inconsistent results of epidural steroid trials. More well-designed randomized trials are needed to guide appropriate use of injection therapy for back pain.

Pain management presents a major challenge to healthcare providers because of its complex natural history and unclear etiology. Clinical decision making for diagnosing and treating chronic pain is difficult due to the subjective nature of pain. Although there are clinical studies for facet injections, the results vary with respect to the degree and duration of pain relief and it is difficult to standardize treatment models.

In a retrospective multicenter study of 262 participants, Cohen and colleagues (2008) compared lumbar zygapophyseal joint radiofrequency denervation success rates between the conventional 50% or more thresholds and the more stringently proposed at least 80% cutoff. A total of 145 participants had greater than 50% but less than 80% relief after medial branch block and 117 obtained 80% relief. The authors concluded that using more stringent pain relief criteria when selecting candidates is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment.

Diagnostic medial branch blocks have been established as the standard for diagnosing facetogenic pain. In a prospective multicenter study Cohen and colleagues (2013) evaluated optimal cutoff threshold for diagnostic lumbar facet blocks. A positive diagnostic block was defined as pain relief of more than 50% during anesthetic procedure and individual with ability to carry out previously painful maneuvers. The authors concluded that employing more stringent selection criteria would likely result in withholding treatment from a substantial number of individuals, without improving success rate.

Definitions

Non-radicular back pain: Pain which does not radiate along a dermatome (sensory distribution of a single root). Appropriate imaging does not reveal signs of spinal nerve root compression and there is no evidence of spinal nerve root compression seen on clinical exam.

Radicular back pain: Pain which radiates along a dermatome (sensory distribution of a single root) into an upper or lower extremity. Evidence of spinal nerve root compression may be seen on clinical exam and supported by appropriate imaging (generally Magnetic Resonance Imaging [MRI]) studies.

Radiculopathy: Radiculopathy is characterized by pain which radiates from the spine to extend outward to cause symptoms away from the source of the spinal nerve root irritation.

Straight Leg Raise Test: In the supine position and the leg is elevated, with the knee held in extension by the clinician, up to 70 degrees; a positive test reproduces radicular pain along the path of a nerve root in the 30- to 70-degree range of elevation.

References

Peer Reviewed Publications:

  1. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain.  Spine. 2009; 34(10):1078-1093.
  2. Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine. 2009; 34(10):1066-1077.
  3. Cohen SP, Stojanovic MP, Crooks M, et al. Lumbar zygapophysical (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J. 2008; 8:498-504.
  4. Cohen SP, Strassels SA, Kurihara C, et al. Establishing a optimal "cutoff" threshold for diagnostic lumbar facet blocks: A prospective correlational study. Clin J Pain. 2013; 29:382-391.
  5. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12(4):699-802.
  6. Manchikanti L, Singh V, Falco FJ, et al. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. 2010a; 13(6):535-548.
  7. Manchikanti L, Singh V, Falco FJ, et al. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. 2010b; 13(5):437-450.
  8. Manchikanti L, Singh V, Falco FJ, et al. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010c; 7(3):124-135.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Pain Society (APS) and American Academy of Pain Medicine (ASPM). Clinical guideline for the evaluation and management of low back pain: Evidence review. 2009. Available at: http://www.americanpainsociety.org/uploads/pdfs/LBPEvidRev.pdf. Accessed on September 18, 2013.
  2. American Society of Anesthesiologists (ASA). Task Force on Pain Management: General practice guidelines for chronic pain management. Anesthesiology 1997; 86(4):995-1004.
  3. National Government Services. Jurisdiction I. Local Coverage Determination for Pain Management (L28529). Revision 09/07/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on September 18, 2013.
  4. National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. 2009. Available at: http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf . Accessed on September 18, 2013.
  5. Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008; (3):CD001824.
Web Sites for Additional Information
  1. American Academy of Orthopaedic Surgeons. Spinal injections. November 2009. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00560. Accessed on September 18, 2013.
  2. MedlinePlus. Back pain. August 16, 2012. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html#cat3. Accessed on September 18, 2013.
  3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Back pain. August 16, 2012. Available at: http://www.nlm.nih.gov/medlineplus/backpain.html. Accessed on September 18, 2013.
Index

Diagnostic block
Diagnostic facet injection
Facet block
Medial branch block
Therapeutic block
Therapeutic facet injection

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Revised11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified medically necessary criteria for facet injections. Updated Definitions, References and Websites.
New05/09/2013MPTAC review. Initial document development.