PHC Medical Necessity Criteria for Pain Management …



22510 – 22515 Percutaneous vertebroplasty and percutaneous vertebral augmentationApproval will only be considered in patients with Acute vertebral compression fracture (less than 3 months), debilitated and unable to tolerate conservative therapy (minimum of 3 weeks of conservative therapy should be tried first), orVertebral hemangioma failing conservative therapy, or Malignancy related compression fracture with no neurologic symptoms and pain interfering with activities of daily living. Recent well controlled study shows no benefit over placebo for longstanding vertebral fractures/pain. (Reference: Treatment of Symptomatic Osteoporotic Spinal Compression Fractures, Journal of the American Academy of Orthopedic Surgeons, March 2011; Spine J. 2012 Nov; 12(11): 998-1005)27096 SI joint injectionActivity modification for 4 weeks required, unless pain is very severe. Repeat injections only approved if at least 50% decrease in pain lasting at least 8 weeks. Maximum of 3 SI joint injections with steroid covered per 12 months. 62290 to 62291 Discography, Lumbar and CervicalCurrent medical evidence is that harm outweighs benefit for this procedure. It will only be covered if new and better studies are submitted demonstrating a benefit. Physician review required. (Reference: New York Medicaid redesign team: Basic Benefit review workgroup final recommendations, Nov. 1, 2011)62360 to 62362 Implantable or replacement device for intrathecal or epidural drug infusion; subcutaneous reservoirTreatment of severe, chronic or intractable pain and disability of malignant or nonmalignant origin as choice of last resort after patient has been unresponsive to opioid medications, appropriate nerve blocks, epidural injections and Evaluation by a multidisciplinary team which should include physical, functional and psychological evaluation.Preliminary trial of opioids by a temporary catheter substantiates acceptable pain relief with minimal side effects.63650, 63655, 63658, 63661-63664, 63685, 63688Insertion, revision, or removal of spinal neurostimulatorCovered for the following conditions after a temporary stimulator in the epidural space demonstrates at least 50% relief of pain documented by a pain log for a minimum 48 hour trial:Failed back syndrome with low back pain and significant radicular pain;Complex regional pain syndromeLast resort treatment for severe chronic neuropathic pain resulting from actual damage to peripheral nerves, lumbosacral arachnoiditis and radiculopathies, phantom limb/stump pain, peripheral neuropathy, or incomplete spinal cord injury that is refractory to 12 or more months of standard therapy.64479 to 64484 Transforaminal epidural injectionSame as InterQual? except: remove requirement for documentation of trial of NSAIDS; Progress note must document a history of radicular symptoms and imaging must document nerve root impingement. If MRI shows spinal stenosis with no significant impingement, epidural injection is not medically indicated. A minimum of 30 days conservative treatment before eligible for epidural steroid injection. For repeat injections, a minimum of 50% improvement in pain symptoms lasting 8 weeks from the prior epidural injection is required.Maximum of 2 levels of transforaminal epidural injections of the spine per 3 months. This may be 2 levels on the same side or 1 level bilaterally. The interval between injections per site must be no more frequently than every 3 months, and the maximum number of injections per site is 3 per year.64490 to 64495 Paravertebral facet injections and medial branch blocksInitial injection: Same as InterQual? criteria, except documentation of physical therapy for 6 weeks and NSAIDs are not needed. Patient must have a minimum of 12 weeks of symptoms consistent with facet joint pain. The progress note should document a physical examination of the back, including pain elicited with movement. No more than 3 levels will be approved, either 3 levels unilaterally or 3 levels bilaterally. Maximum of 2 MBB per level per year. Repeat Injections: A pain log must be submitted showing that the pain relief from the previous injection was consistent with the anesthetic agent used, with documentation of at least 50% reduction in pain. For example, for a pure bupivacaine block, this is about 2-3 hours; bupivacaine plus minimal dose steroid block could be up to 3-4 days for medial branch blocks versus a month to several months for facet joint block.64633 to 64636 Destruction by neurolytic agent, paravertebral facet jointInterQual? criteria followed. For repeat procedures, the minimal interval between radioablation procedures at the same level is every 6 months. 72285, 72295 Cervical, Thoracic, Lumbar discographySame as 62290 and 62291 above. ................
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