National Medical Policy Subject:

Facet Joint Injections

Policy Number:

NMP44

Effective Date*:

October 2003

Updated:

July 2016

This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State's Medicaid manual(s), publication(s), citations(s) and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use

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Source National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other

Reference/Website Link

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy: http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx MLN Matters Number: MM6518 Revised. Related Change Request (CR) #: 6518. July 31, 2009. Appropriate Use of Modifier 50 and Add-On Current Procedural Terminology Codes (CPT) for Facet Joint Injection Services: https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM6518.pdf MLN Matters Number: SE1102 Revised August 14, 2012. Inappropriate Medicare Payments for Transforaminal Epidural Injection Services: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1102.pdf

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Use Health Net Policy

Instructions Facet Joint Injections Jul 16

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Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance.

Current Policy Statement Health Net, Inc. considers facet joint injections (facet joint nerve blocks) medically necessary in the management of chronic back or neck pain (continuous or intermittent pain persisting 3 months or more) unresponsive to conservative measures in patients suspected of having pain originating in the facet joint, in whom radiculopathy has been ruled out by either physical exam/MRI/CT/ electromyogram, when used for any of the following: 1. As a diagnostic trial to determine the true origin of the patient’s pain where there is a discrepancy between known pathology and complaints or findings (e.g., a disc lesion at one level and pain at another); or 2. As a therapeutic injection (paravertebral facet joint block) intended to allow the patient to participate in the rehabilitation process (e.g., physical therapy) 3. To assess the role and contribution of the facet syndrome when other sources of chronic pain are thought to be present 4. Performed when it is unclear when a patient’s pain is central or peripheral in origin. Note: Consistent with the Agency for Healthcare Research and Quality (AHRQ) guideline on the treatment of acute back pain, Health Net Inc. considers facet joint injections not medically necessary for the treatment of acute back pain, defined as a duration of illness of less than 3 months. Such treatment has not been shown to be effective.

Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.

ICD-9 Codes 720.0 721.1 721.2 721.3 721.42 721.90

Spinal enthesopathy Cervical spondylosis without myelopathy Thoracic spondylosis without myelopathy Lumbosacral spondylosis without myelopathy (Facet Arthropathy) Spondylosis with myelopathy, lumbar region Spondylosis of unspecified site without mentic of myelopathy

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722.71 722.72 722.73 722.81 722.82 722.83 723.1 724.00 724.01 724.02 724.09 724.1 724.2 724.3 724.8 738.4 756.11 756.12

Intervertebral cervical disc disorder with myelopathy Intervertebral thoracic disc disorder with myelopathy Intervertebral lumbar disc disorder with myelopathy Postlaminectomy syndrome, cervical region Postlaminectomy syndrome, thoracic region Postlaminectomy syndrome, lumbar region Cervicalgia Spinal stenosis, unspecified region other than cervical Spinal stenosis, of thoracic region Spinal stenosis of lumbar region Spinal stenosis, other region other than cervical Pain in thoracic spine Lumbago Sciatica Facet syndrome Acquired spondylolisthesis Spondylolysis, congenital Congenital spondylolisthesis

ICD- 10 Codes M43.10-M43.19 M46.0-M46.09 M47.812 M47.814 M47.817 M47.16 M47.819 M48.00 M48.04 M48.06 M48.08 M50.00-M50.03 M51.04- M51.07 M54.08 M54.2 M54.30 M54.5 M54.6 Q76.2

Spondylolisthesis Spinal enthesopathy Spondylosis without myelopathy or radiculopathy, cervical region Spondylosis without myelopathy or radiculopathy, thoracic region Spondylosis without myelopathy or radiculopathy, Lumbosacral region Other spondylosis with myelopathy, lumbar region Spondylosis without myelopathy or radiculopathy, site unspecified Spinal stenosis, site unspecified Spinal stenosis, thoracic region Spinal stenosis, lumbar region Spinal stenosis, sacral and sacrococcygeal region Cervical disc disorder with myelopathy Thoracic, thoracolumbar and lumbosacral Intervertebral disc disorders with myelopathy Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region Cervicalgia Sciatica, unspecified side Low back pain Pain in thoracic spine Congenital spondylolisthesis

CPT Codes 64490

64491

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy innervating that joint) with image guidance Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level

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64492

64493

64494

64495

77003

HCPCS Codes J-Code J-Code

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional levels Injection(s), diagnostic or therapeutic agent, paravertebral Facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or ct) lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral Facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or ct) lumbar or sacral; second level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or ct) lumbar or sacral; third and any additional level(s) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction For anesthetic agent used For steroid (if used in addition to anesthetic

Scientific Rationale – Update July 2016 Manchikanti et al (2016) evaluated and update the clinical utility of therapeutic lumbar, cervical, and thoracic facet joint interventions in managing chronic spinal pain in a systematic review. The available literature. The quality assessment criteria utilized were the Cochrane Musculoskeletal Review Group criteria and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized trials and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for observational studies. The level of evidence was classified at 5 levels from Level I to Level V. Data sources included relevant literature identified through searches on PubMed and EMBASE from 1966 through March 2015, and manual searches of the bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake consumption. A total of 21 randomized controlled trials meeting appropriate inclusion criteria were assessed in this evaluation. A total of 5 observational studies were assessed. In the lumbar spine, for long-term effectiveness, there is Level II evidence for radiofrequency neurotomy and lumbar facet joint nerve blocks, whereas the evidence is Level III for lumbosacral intraarticular injections. In the cervical spine, for long-term improvement, there is Level II evidence for cervical radiofrequency neurotomy and cervical facet joint nerve blocks, and Level IV evidence for cervical intraarticular injections. In the thoracic spine there is Level II evidence for thoracic facet joint nerve blocks and Level IV evidence for radiofrequency neurotomy for long-term improvement. The reviewers concluded the evidence for long-term improvement is Level II for lumbar and cervical radiofrequency neurotomy, and therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine; Level III for lumbar intraarticular injections; and Level IV for cervical intraarticular injections and thoracic radiofrequency neurotomy. The limitations of this systematic review include an overall paucity of high quality studies and more specifically the lack of investigations related to thoracic facet joint injections. Facet Joint Injections Jul 16

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Scientific Rationale – Update July 2015 Proietti et al (2014) evaluated the effectiveness of facet joints injections in lumbar facet syndrome correlating clinical results to the sagittal contour of the spine. Facet joints degree degeneration was evaluated using MRI according to Fujiwara classification. Sagittal contour of the spine was evaluated according to Roussouly classification. The clinical results were evaluated with visual analog scale (VAS) at regular intervals. Twenty-eight (70 %) of the 40 patients had clinical symptoms improvement, 12 (30 %) showed no benefit. There was a statistical significant correlation between postoperative VAS value improvement and Roussouly spine type 1 and 3 (p = 0.003). The benefit was more durable in patients with grade 2 or 3 degeneration. The authors concluded facet joints injections have a more effective diagnostic than therapeutic value. The procedure could, however, give a temporary pain relief in cases with an overload of the facet joints due to lumbar hyperlordosis. Huang et al (2014) sought to to demonstrate the effectiveness of lumbar facet joint injection for piriformis myofascial pain syndrome. Fifty-two patients with chronic myofascial pain in the piriformis muscle each received a lumbar facet injection into the ipsilateral L5-S1 facet joint region, using the multiple insertion technique. Subjective pain intensity, trunk extension range, and lumbar facet signs were measured before, immediately after, and 2 weeks after injection. Thirty-six patients received follow-up for 6 months. Immediately after the injection, 27 patients (51.9%) had complete pain subsidence, 19 patients (36.5%) had pain reduction to a tolerable level, and only 6 patients (11.5%) had no pain relief to a tolerable level. Mean pain intensity was reduced from 7.4±0.9 to 1.6±2.1 after injection (P