Epidural Corticosteroid Injection for Back Pain - Presbyterian ...

Epidural Corticosteroid Injections for Back PainMPM 5.9DisclaimerMedical PolicyOriginal Effective Date: 05-17-10Revised Date: 03-27-13Page 1 of 3Refer to the member’s specific benefit plan and Schedule ofBenefits to determine coverage. This may not be a benefit onall plans or the plan may have broader or more limitedbenefits than those listed in this Medical Policy.DescriptionEpidural corticosteroid injections are utilized in the treatment of discrelateddiseases. Epidural injections are most effective in those caseswhere the radicular pain is prominent but neuralgic findings are minimaland conservative therapies (rest, physical therapy and use of antiinflammatoryagents/analgesics) have failed.This policy does not apply to acute pain conditions, such as control ofpost-surgical pain or obstetrical use during labor and delivery.CoverageDetermination/ClinicalIndicationsPrior Authorization is required. Log on to Pres Online tosubmit a request: https://ds.phs.org/preslogin/index.jspEpidural corticosteroid injections are covered when all of the followingconditions are met and are allowed 3 times over a 6 month period:1. Significant lumbar radicular pain, such as leg pain or paresthesia,either acute or an exacerbation of a chronic condition; and2. The provider has ruled out other causes of pain, such as a nonspinalorigin for pain; and3. Physical examination consistent with lumbar radiculopathy; examplesinclude:• Positive straight leg raising test• Diminished or absent reflex• Motor weakness;and4. Treatment goal is short-term relief of disabling pain; and5. Absence of bleeding tendencies, or discontinuation of anticoagulanttherapy prior to procedure; andNot every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefitplan and Schedule of Benefits to determine coverage.

Epidural Corticosteroid Injection for Back PainMPM 5.9Medical PolicyOriginal Effective Date: 05-17-10Revised Date: 03-27-13Page 3 of 3References:1. Milliman Care Guidelines®. Ambulatory Care. 14 th Edition. EpiduralCorticosteroid Injection. ACG: A-0225(AC) Last update: 02-09-10. Last Update02-02-12.2. Centers for Medicare and Medicaid Services. Pinnacle Business Solutions, Inc.Local Coverage Determination L13423. Epidural Injections. Revision effectivedate: 10-01-09. Revised 10-01-11.Approval Clinical Quality Committee: Mark Whitaker MDSignatures:Medical Director:Albert Rizzoli MDDate March 27, 2013Approved:Publication 05-17-10: Original effective dateHistory: 05-26-10: Revision05-25-11: Annual Review & Revision06-27-12: Annual Review & Revision03-27-13: Corrected format page 2.This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and isdeveloped to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) HealthServices staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not atreatment guide and should not be used as such.For those instances where a member does not meet the criteria described in these guidelines, additionalinformation supporting medical necessity is welcome and may be utilized by the medical director in reviewing thecase. Please note that all Presbyterian medical policies are available on the Internet at:http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htmNot every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefitplan and Schedule of Benefits to determine coverage.