CLINICAL GUIDELINES eviCore

Clinical Guidelines Evicore-Free PDF

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BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. Interventional Pain Management,CMM 200 Epidural Steroid Injections ESI 3. CMM 201 Facet Joint Injections Medial Branch Blocks 16. CMM 202 Trigger Point Injections 23,CMM 203 Sacroiliac Joint Injections 31. CMM 204 Prolotherapy 36, CMM 205 Chemodenervation Botulinium Toxin Injection 39. CMM 207 Epidural Adhesiolysis 45, CMM 208 Radiofrequency Joint Ablations Denervations 49. CMM 209 Regional Sympathetic Blocks 56, CMM 210 Implantable Intrathecal Drug Delivery Systems 61.
CMM 211 Spinal Cord Stimulators 68,CMM 308 Thermal Intradiscal Procedures 69. 2018 eviCore healthcare All rights reserved Page 2 of 73. 400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. CMM 200 Epidural Steroid Injections ESI,CMM 200 1 Definitions 4. CMM 200 2 General Guidelines 5, CMM 200 3 Indications Selective Nerve Root Block SNRB 6. CMM 200 4 Indications Epidural Steroid Injections Transforaminal. Interlaminar or Caudal 6,CMM 200 5 Non Indications SNRB 7. CMM 200 6 Non Indications ESI 7,CMM 200 7 Procedure CPT Codes 8.
CMM 200 8 References 9, 2018 eviCore healthcare All rights reserved Page 3 of 73. 400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. CMM 200 1 Definitions, Transforaminal epidural steroid injection ESI is a therapeutic injection of contrast. absent allergy to contrast performed at a single or multiple spinal levels followed by the. introduction of a corticosteroid and possibly a local anesthetic by inserting a needle into. the neuroforamen under fluoroscopic or computed tomography CT guidance. Selective Nerve Root Block SNRB is a diagnostic injection of contrast absent allergy. to contrast of a single nerve root to assist with surgical planning followed by the introduction. of a local anesthetic by inserting a needle into the neuroforamen under fluoroscopic or. computed tomography CT guidance SNRB s are erroneously referred to as. Transforaminal Epidural Steroid Injection TFESI although technically SNRB s involve the. introduction of anesthetic only and are used for diagnostic purposes. Interlaminar epidural steroid injection ESI is an injection of contrast absent allergy to. contrast followed by the introduction of a corticosteroid and possibly a local anesthetic. into the epidural space of the spine either through a paramedian or midline interlaminar. approach under fluoroscopic guidance, Caudal epidural steroid injection ESI is an injection of contrast absent allergy to. contrast followed by the introduction of corticosteroids and possibly a local anesthetic. into the epidural space of the spine by inserting a needle through the sacral hiatus under. fluoroscopic guidance into the epidural space at the sacral canal. Radiculopathy for the purpose of this policy is defined as the presence of pain. dysaethesia s or paraesthesia s reported by the individual in a specified dermatomal. distribution of an involved named spainl root s causing significant functional limitations. i e diminished quality of life and impaired age appropriate activities of daily living and. EITHER of the following, Documentation of ONE or MORE of the following concordant with nerve root. compression of the involved named spinal root s demonstrated on a detailed. neurologic examination within the prior three 3 months. Epidural Steroid Injections ESI, Loss of strength of specific named muscle s or myotomal distribution s.
Altered sensation to light touch pressure pin prick or temperature in the. sensory distribution,Diminished absent or asymmetric reflex es. Documentation of EITHER of the following performed within the prior 12 months. A concordant radiologist s interpretation of an advanced diagnostic imaging. study MRI or CT of the spine demonstrating compression of the involved. named spinal nerve root s, Electrodiagnostic studies EMG NCV s diagnostic of nerve root compression. of the involved named spinal nerve root s, Radicular pain is pain which radiates to the lower extremity along the course of a. spinal nerve root typically resulting from compression inflammation and or injury to the. nerve root, Radiculitis is defined for the purpose of this policy as radicular pain without objective. neurological findings on physical examination, 2018 eviCore healthcare All rights reserved Page 4 of 73.
400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. Spinal stenosis refers to the narrowing of the spinal canal usually due to spinal. degeneration that occurs with aging It may also be the result of spinal disc herniation. osteoarthritis or a tumor Lumbar spinal stenosis results in low back pain as well as pain. or abnormal sensations in the legs thighs feet or buttocks or loss of bladder and bowel. control Neurogenic claudication is often a clinical condition that results from spinal. CMM 200 2 General Guidelines, The determination of medical necessity for the performance of a selective nerve root. block SNRB or a therapeutic epidural steroid injection is always made on a case by. case basis, Please note this guideline does not apply to epidural injections administered for. obstetrical or surgical epidural anesthesia, An epidural steroid injection should be performed with the use of fluoroscopic or CT. guidance and the injection of a contrast with the exception of an emergent situation or. when fluoroscopic CT guidance or the injection of contrast is contraindicated e g. The use of an indwelling catheter to administer a continuous infusion intermittent bolus. should be limited to use in a hospital setting only It is inappropriate to represent the use of. a catheter for single episode injection s that is are commonly performed in an outpatient. setting as an indwelling catheter for continuous infusion intermittent bolus. There is insufficient scientific evidence to support the scheduling of a series of three. injection in either a diagnostic or therapeutic approach The medical necessity of. subsequent injections should be evaluated individually and be based on the response of. the individual to the previous injection with regard to clinically relevant sustained. reductions in pain decreased need for medication and improvement in the individual s. functional abilities,Epidural Steroid Injections ESI. Selective nerve root blocks performed for the purpose of treating pain may be termed. therapeutic selective nerve root blocks There is insufficient evidence to support the. clinical utility of therapeutic selective nerve root bocks. When performing transforaminal blocks SNRB no more than two 2 nerve root levels. should be injected during the same session procedure. When medical necessity criteria is met a total of three 3 epidural steroid injection per. episode of pain may be performed during a 12 month period of time and no more than. four 4 epidural steroid injections per region per year may be performed. Additionally when medical necessity criteria are met for a cervical thoracic interlaminar. and or cervical thoracic transforaminal epidural steroid injection ES advanced. diagnostic imaging should be performed within 12 months prior to the injection. 2018 eviCore healthcare All rights reserved Page 5 of 73. 400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. CMM 200 3 Indications Selective Nerve Root Block SNRB. A diagnostic selective nerve root block SNRB performed at a single nerve root. involving the introduction of anesthetic only is considered medically necessary. when attempting to establish the diagnosis of radicular pain including radiculitis or. radiculopathy when the diagnosis remains uncertain after standard evaluation. neurologic examination radiological studies and electrodiagnostic studies in the. following clinical situations, When the physical signs and symptoms differ from that found on imaging studies.
When there is clinical evidence of multi level nerve root pathology. When the clinical presentation is suggestive but not typical for both nerve root. and peripheral nerve or joint disease involvement, When the clinical findings are consistent with radiculopathy in a dermatomal. distribution but the imaging studies do not corroborate the findings positive. straight leg raise test, When the individual has had previous spinal surgery. For the purposes of surgical planning, A second selective nerve root block is considered medically necessary when the. following criteria are met,Evidence of multilevel pathology. It has been at least two weeks since the prior injection. CMM 200 4 Indications Epidural Steroid Injections Transforaminal. Interlaminar or Caudal, An epidural steroid injection is considered medically necessary for ANY of the.
following indications when the associated medical necessity criteria are met. For treatment of presumed radiculopathy when there has been failure of at least six. 6 weeks of conservative treatment e g exercise physical methods including. physical therapy and or chiropractic care nonsteroidal anti inflammatory drugs. Epidural Steroid Injections ESI,NSAID s and or muscle relaxants. For treatment of presumed radiculitis or radicular pain when ALL of the following. criteria are met, Radicular pain with or without motor weakness which follows a specified. dermatomal distribution of an involved named spinal root s. A positive straight leg raise crossed leg raise and or Spurling s. Failure of at least six 6 weeks of conservative treatment e g exercise. physical methods including physical therapy and or chiropractic care NSAID s. and or muscle relaxants, When a transforaminal epidural steroid injection is performed in addition to an intra. articular facet joint injection with synovial cyst aspiration when the following criteria. Advanced diagnostic imaging studies e g MRI CT CT myelogram confirm. compression or displacement of the corresponding nerve root by a facet joint. synovial cyst, 2018 eviCore healthcare All rights reserved Page 6 of 73. 400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. Clinical correlation with the individual s signs and symptoms of radicular pain or. radiculopathy based on history and physical examination. As an initial trial when there is evidence of symptomatic spinal stenosis and ALL of. the following criteria are met, Diagnostic evaluation has ruled out other potential causes of pain.
MRI or CT with or without Myelography within the past twelve 12 months. demonstrates severe spinal stenosis at the level to be treated. Significant functional limitations resulting in diminished quality of life and. impaired age appropriate activities of daily living. Failure of at least four 4 weeks of conservative treatment e g exercise. physical methods including physical therapy and or chiropractic care NSAIDS. and or muscle relaxants, A repeat epidural steroid injection when at least TWO of the following criteria are. met for two or more week s duration,50 or greater pain relief. Increase in the level of function physical activity e g return to work. Reduction in the use of pain medication and or additional medical services such. as physical therapy chiropractic case,CMM 200 5 Non Indications SNRB. Diagnostic and therapeutic SNRBs are considered not medically necessary for ANY. other indication, A second repeat selective nerve root block is considered not medically necessary for. either of the following, An inadequate response to the first block as determined by the injectate utilized.
An absence of multilevel pathology when the first injection is performed under. fluoroscopy CT guidance using contrast,Epidural Steroid Injections ESI. CMM 200 6 Non Indications ESI, An epidural steroid injection performed with ultrasound guidance is considered. experimental investigational or unproven, An epidural steroid injection is considered not medically necessary for ALL of the. When performed without imaging guidance i e CT fluoroscopy. Transforaminal epidural steroid injection performed at more than two 2 nerve. root levels during the same session procedure, An interlaminar epidural steroid injection performed at more than a single level. during the same session procedure, Epidural steroid injection administered in the same region as other spinal.
injections on the same day of service, Performed in isolation i e without the individual participating in an active. rehabilitation program home exercise program functional restoration program. Repeating epidural steroid injections more frequently than every seven 7 days. More than three 3 spidural steroid injections per episode of pain. 2018 eviCore healthcare All rights reserved Page 7 of 73. 400 Buckwalter Place Boulevard Bluffton SC 29910 800 918 8924 www eviCore com. BridgeSpan Comprehensive Musculoskeletal Management Guidelines V20 0 2018. More than four 4 epidural steroid injections per region per year. For axial spinal pain i e absence of radiculopathy myelopathy. myeloradiculopathy, A caudal epidural steroid injection for levels above L4 L5 without supporting. ULGJH6SDQ CMM 200 Epidural Steroid Injections ESI CMM 200 1 Definitions 4 CMM 200 2 General Guidelines 5 CMM 200 3 Indications Selective Nerve Root Block SNRB 6

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