Subject:
Epidurography, Radiological Supervision and Interpretation
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Diagnostic epidurography is performed to assess the structure of the epidural space in the spine by injecting contrast dye under fluoroscopic guidance.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
CMM-404: Epidurography
| CMM-404.1: Definitions |
| CMM-404.2: General Guidelines |
| CMM-404.3: Indications |
| CMM-404.4: Non-Indications |
| CMM-404.5: Procedure (CPT®) Codes |
CMM-404.1: Definitions
Epidurography is radiography of the spine after a radiopaque medium has been injected into the epidural space. It is used as a diagnostic study to potentially find the source of pain in the spine that may not be evident on imaging studies (i.e., MRI/CT) and is designed to assist in making decisions for treatment of the patient. A separate report from another spinal procedure, such as an epidural steroid injection, is necessary. The report should include a formal radiologic report with all of the following:
® A diagnostic evaluation following the injection of contrast
® Permanent images in multiple planes of a specific anatomic region
® The degree of fluid flow (or lack thereof) in the epidural space with notation of scarring or nerve impingement or enlargement
(Please note: An injection of contrast during an image guided epidural steroid injection is not an epidurogram.)
CMM-404.2: General Guidelines
Epidurography (CPT®72275) includes fluoroscopic guidance, epidurogram, documentation of images, and a formal written report. These should not be submitted separately.
CMM-404.3: Indications
Epidurography for initial mapping of the epidural space is considered medically necessary when both of the following are met:
† Medical/surgical history suggests significantly abnormal anatomy of the epidural space
† Diagnostic mapping of anatomy of the epidural space beyond available CT or MRI imaging is required to plan a therapeutic procedure
Epidurography for subsequent mapping of the epidural space is considered medically necessary when all of the following are met:
† Medical/surgical history suggests significantly abnormal anatomy of the epidural space
† Diagnostic mapping of anatomy of the epidural space beyond available CT or MRI imaging is required to plan a therapeutic procedure
† Clinically significant change in anatomy since the initial procedure
CMM-404.4: Non-Indications
Epidurography for mapping of the epidural space is not considered medically necessary when used for determining needle placement during a procedure (e.g., epidural steroid injection).
CMM-404.5: Procedure (CPT®) Codes
| This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor. |
| CPT® | Code Description/Definition |
72275 | Epidurography, radiological supervision and interpretation |
| This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so. |
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Epidurography, Radiological Supervision and Interpretation
Epidurography
References:
1. Dorland’s Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc.
2. National Government Services, Inc. Local coverage determination for Pain Management (L33622)
3. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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