† 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. SNRBs are erroneously referred to as transforaminal epidural steroid injection (TFESI), although technically SNRBs involve the introduction of anesthetic only and are used for diagnostic purposes.

® Selective nerve root blocks (SNRBs) performed for the purpose of treating pain (i.e., repeat SNRB at the same level) may be termed therapeutic selective nerve root blocks. There is insufficient evidence to support the clinical utility of therapeutic selective nerve root bocks (SNRBs).

† Caudal epidural steroid injection (CESI) 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, dysesthesia(s), or paresthesia(s) reported by the individual in a level-specific referral pattern of an involved named spinal 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:
¡ 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).

† Radiculitis is defined, for the purpose of this policy, as radicular pain without objective neurological findings on physical examination.

† 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 stenosis.

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)


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 policy does not apply to epidural injections administered for obstetrical or surgical epidural anesthesia or for perioperative pain management. It only applies to the injection of anesthetic, corticosteroid, and/or contrast agent and not to other injectates including but not limited to Spinraza, chemotherapy, neurolytic substances, antispasmodics, antibiotics, antivirals, biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.), and any other injectates.

† 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., pregnancy).

† 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.

† When performing transforaminal epidural steroid injections (TFESIs) or selective nerve root blocks (SNRBs), 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 injections (ESIs) per episode of pain, per region may be performed in six (6) months, not to exceed four (4) epidural steroid injections (ESIs) per region in 12 months.

† Additionally, when medical necessity criteria are met for an initial or repeat cervical/thoracic interlaminar (ILESI) and/or a cervical/thoracic transforaminal epidural steroid injection (TFESI), advanced diagnostic imaging should be performed within 24 months prior to the initial or repeat injection.


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 ANY of 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 level-specific referral pattern of an involved named spinal root(s), 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 response to the prior block of less than 80% relief based on the injectate utilized
® Evidence of multilevel pathology
® It has been at least 7 days since the prior block

® 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 [NSAID’s] and/or muscle relaxants).
® 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 level-specific referral pattern 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).
® 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 moderate to 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)

® 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
® Clinical correlation with the individual’s signs and symptoms of radicular pain or radiculopathy, based on history and physical examination.

® 50% or greater relief of radicular pain
® 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

† Diagnostic selective nerve root blocks (SNRBs) are considered not medically necessary for injectables other than anesthetic, corticosteroid, and/or contrast agent and for any other indication (e.g., post-herpetic neuralgia).

† Therapeutic selective nerve root blocks (SNRBs) (i.e., a repeat SNRB at the same level) are considered investigational for any indication.

† A diagnostic selective nerve root block (SNRB) at a spinal level other than the initial level is considered not medically necessary for ALL of the following:

® Injectables other than anesthetic, corticosteroid, and/or contrast agent
® An adequate 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
® Repeating diagnostic selective nerve root blocks (SNRBs) more frequently than every seven (7) days

† An epidural steroid injection is considered not medically necessary for ALL of the following:

® Injectables other than anesthetic, corticosteroid, and/or contrast agent
® When performed without imaging guidance (i.e., CT, fluoroscopy)
® Transforaminal epidural steroid injection (TFESI) performed at more than two (2) nerve root levels during the same session/procedure.
® An interlaminar epidural steroid injection (ILESI), performed at more than a single level during the same session/procedure
® Epidural steroid injection (ESI) administered in the same region as other spinal injections on the same day of service with the exception of an epidural steroid injection performed with an intra-articular facet joint injection with synovial cyst aspiration in accordance with criteria in CMM-200.4 above.
® 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 14 days
® More than three (3) epidural steroid injections (ESIs) per episode of pain, per region in 6 months
® More than four (4) epidural steroid injections (ESIs) per region, per 12 months
® For axial spinal pain (i.e., absence of radiculopathy, myelopathy, myeloradiculopathy)
® A caudal epidural steroid injection (CESI) for levels above L4-L5 without supporting clinical rationale for use of alternative approaches (e.g., translaminar, transforaminal)
® Performed for post-herpetic neuralgia

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.
CPT®	Code Description/Definition
62320	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT)
62322	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323	Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT)
62324	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT)
62326	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62327	Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT)
64479	Injection(s), anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
+64480	Injection(s), anesthetic agent and/or transforaminal epidural with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
64483	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
+64484	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
CPT®	Codes Considered Investigational
0228T	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
0229T	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)
0230T	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level
0231T	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)
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 health plan and is based on the individual’s policy or benefit entitlement structure as well as claims processing rules.

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.

________________________________________________________________________________________

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.

___________________________________________________________________________________________________________________________

Index:
Epidural Steroid Injections
Cervical or Thoracic Epidural Steroid Injections, Interlaminar Approach
Cervical Epidural Steroid Injections
Thoracic Epidural Steroid Injections
Epidural Steroid Injections, Cervical
Epidural Steroid Injections, Thoracic
Cervical/Thoracic Epidural Steroid Injections, Transforaminal Approach
Cervical/Thoracic Epidural Steroid Injections
Lumbar Epidural Steroid Injections, Caudal or Interlaminar Approach
Epidural Steroid Injections, Lumbar
Caudal Epidural Steroid Injection
Interlaminar Epidural Sterioid Injection
Midline Epidural Steroid Injection
Lumbar Epidural Steroid Injections, Transforaminal Approach
Transforaminal Lumbar Epidural Steroid Injection
Epidural Steroid Injections, Transforaminal, Lumbar

References:
1. Ackerman WE 3rd, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg 2007; 104:1217-1222.

2. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008.

3. Albert H, Manniche C. The Efficacy of Systematic Active Conservative Treatment for Patients with Severe Sciatica. A Single-Blind, Randomized, Clinical, Controlled Trial. Spine. Vol 37, 7. 2012

4. Akuthota V, Bogduk N, Easa J, Obrien D, Patel A, Prather H, Sharma A, Standaert C, Summers, J, Lumbar Transforaminal Epidural Steroid Injections Review & Recommendation Statement. North American Spine Society, January 2013, 28-30.

5. Allen T, Tatli Y, Lutz G. Fluoroscopic percutaneous lumbar zygopophyseal joint cyst ruptur: a clinical outcome study. Spine J. 2009 May;9(5): 387-95.

6. Amoretti N, Huwart L, Foti P, Boileau P, Amoretti M, Pellegrin A, Marcy P, Hauger O. Symptomatic lumbar facet joint cysts treated by CT-guided ntracystic and intra-articular steroid injections. Eur Radiol 2012 Dec; (12): 2836-40

7. Amr YM. Effect of addition of epidural ketamine to steroid in lumbar radiculitis: One-year follow-up. Pain Physician. 2011;14:475-481.

8. Anderberg L, Annertz M, Persson L, et al. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J. 2007;16(3):321-328.

9. Arden N, Price C, Reading I, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology (Oxford). 2005; 44:1399-1406.

10. Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al; WEST Study Group. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology (Oxford) 2005;44:1399-1406.

11. Becker C, Heidersdorf S, Drewlo S, de Rodriguez SZ, Krämer J, Willburger RE. Efficacy of epidural perineural injections with autologous conditioned serum for lumbar radicular compression: An investigator-initiated, prospective, double-blind, reference controlled study. Spine (Phila Pa 1976) 2007;32:1803-1808.

12. Benzon HT, Huntoon MA, Rathmell JP. Improving the safety of epidural steroid injections. JAMA. 2015 May 5;313(17):1713-4. doi: 10.1001/jama.2015.2912.

13. Blankenbaker D, De Smet A, Stanczak J, Fine J. Lumbar radiculopathy: treatment with selective lumbar nerve blocks–comparison of effectiveness of triamcinolone and betamethasone injectable suspensions. Radiology. 2005;237:738-741.

14. Botwin K, Baskin M, Rao S. Adverse effects of fluoroscopically guided interlaminar thoracic epidural steroid injections. Am J Phys Med Rehabil. 2006;85:14-23.

15. Botwin K, Gruber R, Bouchlas C, et. al. Fluoroscopically guided lumbar transforamational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil. 2002;81(12):898-905.

16. Botwin K, Sakalkale D. Epidural steroid injections in the treatment of symptomatic lumbar spinal stenosis associated with epidural lipomatosis. Am J Phys Med Rehabil. 2004;83:926-993.

17. Buttermann G. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am.2004;86-A(4):670-679.

18. Candido KD, Rana MV, Sauer R, Chupatanakul L, Tharian A, Vasic V, Knezevic NN. Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain. Pain Physician. 2013;16:497-511.

19. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634-1640.

20. Chang Chien GC, Knezevic NN, McCormick Z, Chu SK, Trescot Am, Candido KD. Transforaminal versus interlaminar approaches to epidural steroid injections: A systematic review of comparative studies for lumbosacral radicular pain. Pain Physician. 2014;17:E509-E524.

21. Chou R, Loeser J, Owens D, Rosenquist R, Atlas S, Baisden J, Carragee E, Grabois M, Murphy D, Resnick D, Stanos S, Shafer W, Wall E. Interventional Therapies, Surgery, and Interdisciplinarry Rehabilitation for Low Back Pain. An Evidence Based Clinical Practice Guideline From the American Pain Society. Spine 2009 34(10) 1066-77.

22. Cohen SP, Hanling S, Bicket MC, White RL, Veizi E, Kurihara C, Zhao Z, Hayek S, Guthmiller KB, Griffith SR, Gordin V, White MA, Vorobeychik Y, Pasquina PF. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: Multicenter randomized double blind comparative efficacy study. BMJ 2015; 350:h1748.

23. Cohen S, Hayek S, Semenov Y, Pasquina P, White R, Veizi E, Huang J, Kurihara C, Zhoa Z, Guthmiller K, Griffith S, Verdun A, Giampetro D, VorobeychikY. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparitive-effectiveness study. Anesthesiology. 2014 Nov; 121(5): 1045 – 55.

24. Cooper G, Lutz G, Boachie-Adjei O, Lin J. Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy. Pain Physician. 2004; 7:311-317.

25. Dashfield A, Taylor M, Cleaver J, Farrow D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double- blind trial. Br J Anaesth. 2005; 94:514-559.

26. Datta R, Upadhyay KK. A randomized clinical trial of three different steroid agents for treatment of low backache through the caudal route. Med J Armed Forces India. 2011;67:25-33.

27. Delitto A, George S, VanDillen L, Whitman J, Sowa G, Shekelle P, Denninger T, Godges J. Low Back Pain Clinical Practice Guidelines Linked to the Internationaal Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42(4):A1 – A 57. Affirmed by the the American Academy of Physical Medicine and Rehabilitation Board of Governors.

28. DePalma M, Bhargava A, Slipman C. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil. 2005;86(7):1477-1483.

29. Donelson R, Long A, Spratt K, Fung, T. Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. PM R. 2012;4:667.

30. Dreyfuss P, Baker R, Bogduk N. Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med. 2006;7:237-242.

31. Eckel TS, Bartynski WS. Epidural steroid injections and selective nerve root blocks. Tech Vasc Interv Radiol. 2009 Mar 12(1): 11 – 21.

32. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014; 371:11-21.

33. Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain 1998;14:148-151.

34. Furman M, Butler S, Kim R, Mehta A, Simon J, Patel R, Lee T, Reeves R (2012). Injectate volumes needed to reach specific landmarks in S1 transforaminal epidural steroid injections. Pain Medicine. 13(10):1265-1274.

35. Furman M, Mehta A, Kim R, Simon J, Patel R, Lee T, Reeves R (2010). Injectate volumes to reach specific landmarks in lumbar transforaminal epidural steroid injections. PM&R, 2(7), 625-635.

36. Furman MB, Johnson SC. Induced lumbosacral radicular symptom referral patterns: a descriptive study. The Spine Journal. 2019;19: 163-170.

37. Furman MB, Lee TS, Mehta A, Simon JI, Cano WG (2008). Contrast flow selectivity during transforaminal epidural steroid injections. Pain Physician, 11(6), 855-861.

38. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010; 11:1149-1168.

39. Ghai B, Bansal D, Kay JP, Vadaje KS, Wig J. Transforaminal versus parasagittal interlaminar epidural steroid injection in low back pain with radicular pain: A randomized, double-blind, active-control trial. Pain Physician 2014; 17:277-290.

40. Ghai B, Kumar K, Bansal D, Dhatt SS, Kanukula R, Batra YK. Effectiveness of parasagittal interlaminar epidural local anesthetic with or without steroid in chronic lumbosacral pain: A randomized, double-blind clinical trial. Pain Physician 2015;18:237-248.

41. Ghanavatian S, Wie C, et al. Parameters associated with efficacy of epidural steroid injections in the management of post herpetic neuralgia: the Mayo Clinic experience. J Pain Res 2019;12:1279-1286.

42. Hagen K, Hilde G, Jamtvedt G, Winnem M. The cochrane review of advice to stay as active as a single treatment for low back pain and sciatica. Spine. 2002 Aug 15; 27(16): 1736 – 41.

43. Hooten W, Cohen S. Evaluation and treatment of low back pain: a clinically focused review for primary care specialists. Mayo Clin Proc. 2015 Dec;90(12): 1699-718.

44. Huang R, Shapiro G, Lim M, Set al. Cervical epidural abscess after epidural steroid injection. Spine. 2004; 29:E7-E9.

45. Huda N, Bansal P, Gupta SM, Ruhela A, Rehman M, Afzal M. The efficacy of epidural depomethylprednisolone and triamcinolone acetate in relieving the symptoms of lumbar canal stenosis: A comparative study. J Clin Diagn Res 2010;4:2843-2847.

46. Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: A prospective randomized controlled study. Radiology 2007;245:584-590.

47. Kennedy DJ, Plastaras C, Casey E, Visco CJ, Rittenberg JD, Conrad B, Sigler J, Dreyfuss P. Comparative effectiveness of lumbar transforaminal epidural steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Med. 2014;15:548-55.

48. Kerezoudis P, Rinaldo L, Alvi MA, Hunt CL, Qu W, Maus TP, Bydon M. The Effect of Epidural Steroid Injections on Bone Mineral Density and Vertebral Fracture Risk: A Systematic Review and Critical Appraisal of Current Literature. Pain Med. 2018 Jan 2. doi: 10.1093/pm/pnx324.

49. Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, Nygaard O, Hasvold T, Ingebrigtsen T. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011;343:d5278.

50. Karppinen J, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, Nieminen P, Ohinmaa A, Tervonen O, Vanharanta H. Periradicular infiltration for sciatica: A randomized controlled trial. Spine (Phila Pa 1976) 2001;26:1059-1067.

51. Kaye AD, Manchikanti L, Abdi S, et al. Efficacy of epidural injections in managing chronic spinal pain: A best evidence synthesis. Pain Physician. 2015; in press.

52. King W, Miller DC, Smith CC. Systemic Effects of Epidural Corticosteroid Injection. Pain Med. 2018 Feb 1;19(2):404-405.

53. Koh WU, Choi SS, Park SY, Joo EY, Kim SH, Lee JD, Shin JY, Suh JH, Leem JG, Shin JW. Transforaminal hypertonic saline for the treatment of lumbar lateral canal stenosis: A doubleblinded, randomized, active-control trial. Pain Physician. 2013;16:197-211.

54. Koltsov JC, Smuck MW, Zagel A, et al. Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery. The Spine Journal. 2019;19(2):199-205. doi:10.1016/j.spinee.2018.05.034.

55. Kreiner D, Hwang S, Easa J, Resnick D, Baisden J, Dougherty P, Fernand R, Ghiselli G, Haanna A, Lamer T, Lisi A, Mazanec D, Meagher R, Nucci R, Patel R, Sembrano J, Sharma A, Summers J, Taleghani C, Tontz W, Toton J. North American Spine Society Evidence Based Guideline for Multidisciplinary Spine Care. Clinical Guidelines for Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. 2012, page 30.

56. Kreiner D, Shaffer W, Baisden J, Gilbert T, Summers J, Toton J, Hwang S, Mendel R, Reitman C. Evidence – Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. North American Spine Society 2011, 43-44. (43 references) Endorsed by the American Academy of Physical Medicine and Rehabilitation Board of Governors

57. Lee BS, Nault R, Grabowski M, et al. Utility of repeat magnetic resonance imaging in surgical patients with lumbar stenosis without disc herniation. The Spine Journal. 2019;19(2):191-198. doi:10.1016/j.spinee.2018.06.357.

58. Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain. 2009;25:206-210.

59. Lee J, Kim S, Lee I, et al. Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection. AJR Am J Roentgenol. 2006; 187:1427-1431.Lee K, Lin C, Hwang S, et al. Transforaminal periradicular infiltration guided by CT for unilateral sciatica–an outcome study. Clin Imaging. 2005; 29:211-214.

60. Lee JH, Kim DH, Shin KS, Park SJ, Lee GJ, Lee CH, Yang HS. Comparison of clinical efficacy of epidural injection with or without steroid in lumbosacral disc herniation: A systematic review and meta-analysis. Pain Physician 2018; in press.

61. Lipetz, J Pathophysiology of inflammatory degenerative and compressive radiculopathies. PMR Clinics of North America. 2002; Aug: 13(3): 439-49

62. Liu K, Liu P, Liu R, Wu X, Cai M. Steroid for epidural injection in spinal stenosis: A systematic review and meta-analysis. Drug Des Devel Ther. 2015;9:707–716

63. Liu J, Zhou H, Lu L, Li X, Jia J, Shi Z, Yao X, Wu Q, Feng S. The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016 May;95(18):e3373.

64. Lutz G,ShenT. Fluoroscopically guided aspiration of a symptomatic lumbar zygopopheseal joint cyst: a case report. Arch Phys Med Rehabil 2002 Dec; 83(12); 1789-91.

65. Martha J, Swaim B, Wang D, Kim D Hll D, Bode R, Schwartz C. Outcome of percutaneous rupture of lumbar synovialcysts: a case series of 101 patients. Spine J 2009 Nov 9(11) 899-904.

66. Machado LA, de Souza MS, Ferreira PH, Ferreira ML. The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach. Spine (Phila Pa 1976). 2006;31(9):E254–E262.

67. Machado LA, Maher CG, Herbert RD, Clare H, McAuley JH. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Med. 2010;8:10.

68. Macvicar J, King W, Landers MH, Bogduk N. The effectiveness of lumbar transforaminal injection of steroids: A comprehensive review with systematic analysis of the published data. Pain Med. 2013; 14:14-28.

69. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician. 2013;16:S49-S283.

70. Manchikanti L, Benyamin RM, Falco FJ, Kaye AD, Hirsch JA. Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015;473:1940-1956.

71. Manchikanti L, Cash KA, McManus CD, Damron KS, Pampati V, Falco FJE. A randomized, double-blind controlled trial of lumbar interlaminar epidural injections in central spinal stenosis: 2-year follow-up. Pain Physician. 2015;18:79-92.

72. Manchikanti L, Cash KA, McManus CD, Pampati V. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis or facet joint pain. J Pain Res. 2012;5:381-390.

73. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. A randomized, doubleblind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: Results of a 2-year follow-up. Pain Physician. 2013;16:E491- E504.

74. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin R. Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain. J Pain Res. 2012; 5:301-311.

75. Manchikanti L, Cash KA, McManus CD, Pampati V, Fellows B. Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician. 2012;15:371-384.

76. Manchikanti L, Cash KA, Pampati V, Falco FJE. Transforaminal epidural injections in chronic lumbar disc herniation: A randomized, double-blind, active-control trial. Pain Physician. 2014;17:E489-E501.

77. Manchikanti L, Falco FJE, Pampati V, Hirsch JA. Lumbar interlaminar epidural injections are superior to caudal epidural injections in managing lumbar central spinal stenosis. Pain Physician 2014;17:E691-E702.

78. Manchikanti L, Cash KA, Pampati V, Malla Y. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis. J Pain Res. 2012;5:227-236.

79. Manchikanti L, Cash KA, Pampati V, Malla Y. Two-year follow-up results of fluoroscopic cervical epidural injections in chronic axial or discogenic neck pain: A randomized, double-blind, controlled trial. Int J Med Sci. 2014;11:309-320.

80. Manchikanti L, Hirsch JA. An update on the management of chronic lumbar discogenic pain. Pain Manag. 2015;5:373-386.

81. Manchikanti L, Hirsch JA. Clinical management of radicular pain. Expert Rev Neurother. 2015;15:681-693.

82. Manchikanti L, Knezevic NN, Boswell MV, Kaye AD, Hirsch JA. Epidural injections for lumbar radiculopathy and spinal stenosis: A comparative systematic review and meta-analysis. Pain Physician 2016; E365-E410.

83. Manchikanti L, Nampiaparampil DE, Manchikanti KN, et al. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surg Neurol Int. 2015;6:S194- S235.

84. Manchikanti L, Pampati V, Benyamin RM, Boswell MV. Analysis of efficacy differences between caudal and lumbar interlaminar epidural injections in chronic lumbar axial discogenic pain: Local anesthetic alone vs. local combined with steroids. Int J Med Sci. 2015;12:214-222.

85. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: A randomized, controlled, double blind trial with a two year follow-up. Pain Physician 2012;15:273-286.

86. Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJE. A randomized, double-blind, active control trial of the effectiveness of lumbar interlaminar epidural injections in disc herniation. Pain Physician. 2014; 7:E61-E74.

87. Manchikanti L, Singh V, Pampati V, Falco FJE, Hirsch JA. Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: Is one method superior to the other? Korean J Pain. 2015;28:11-21.

88. Manchikanti L, Staats PS. Nampiaparampil DE, Hirsch JA. What is the role of epidural injections in the treatment of lumbar discogenic pain: A systematic review of comparative analysis with fusion and disc arthroplasty. Korean J Pain. 2015;28:75-87.Matz P, Meagher R, Lamet T, Tontz W. Evidence – Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. North American Spine Society 2014, 39. (87 references) Endorsed by the American Academy of Physical Medicine and Rehabilitation Board of Governors

89. McCormick Z, Cushman D, Casey E, Garvan C, Kennedy D, Plastares C. Factors associated with pain reduction after transforaminal epidural steroid injection for lumbosacral radicular pain. Arch Phys Med Rehabil 2014 Dec; 95(12): 2350-6.

90. Melfi R, AprillC. Percutaneous puncture of zygopophyseal joint synovial cyst with flouroscopic guidance. Pain Med 2005 Mar-0Apr;6(2):122-8.

91. Meng H, Fei Q, Wang B, Yang Y, Li D, Li J, Su N. Epidural injections with or without steroids in managing chronic low back pain secondary to lumbar spinal stenosis: a meta-analysis of 13 randomized controlled trials. Drug Des Devel Ther 2015; 9:4657-67.

92. Murakibhavi VG, Khemka AG. Caudal epidural steroid injection: A randomized controlled trial. Evid Based Spine Care J. 2011;2:19-26.

93. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: A randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005;30:857- 862.

94. North American Spine Society (NASS). NASS Coverage Policy Recommendation.: Cervical Epidural Injections and Diagnostic Spinal Nerve Blocks. Lumbar Epidural Injections Facet Joint Intervention. Copyright © 2016 North American Spine Society

95. Park KD, Lee J, Jee H, Park Y. Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil. 2012;91:1039-1050.

96. Park Y, Lee JH, Park KD, Ahn JK, Park J, Jee H. Ultrasound-guided vs. fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: A prospective, randomized, single-blind clinical study. Am J Phys Med Rehabil. 2013;92:575-586.

97. Parr AT, DiwanS, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back pain and lower extremity pain: a systematic review. Pain Physician 2009 Jan-Feb; 12(1): 163 – 88.

98. Patel J, Schneider B, Smith C on behalf of SIS Patient Safety Committee. Intrarticular Corticosteroid Injections and hyperglycemia. 10/4/17.

99. Peng B, Wu, Li Z, Guo JWang X. Chemical Radiculitis. Pain. 2007; Jan (1-2): 11-6.

100. Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: A systematic review and meta-analysis. Ann Intern Med. 2012;157:865-877.

101. Pirbudak L, Karakurum G, Oner U, Gulec A, Karadasli H. Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy. Pain Clinic. 2003;15:247-253.

102. Rados I, Sakic K, Fingler M, Kapural L. Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study. Pain Med. 2011;12:1316-1321.

103. Rathmell JP, Benzon HT, Dreyfuss P, et al. Safegaurds to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122: 974-84. doi: 10.1097/ALN.0000000000000614.

104. Riew KD, Yin Y, Gilula L, et al.. J Bone Joint Surg Am. 2000;82:1589-1593.

105. Riew K, Park J, Cho Y, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am. 2006;88(8):1722-1725.

106. Sabers S, Ross S, Grogg B, Lauder T. Procedure-based nonsurgical management of lumbar zygopophyseal joint cyst-induced radicular pain. Arch Phys Med Rehabil 2005 Sep;86(9): 1767-71.

107. Saifuddin A, Mitchel R, Taylor B. Extradural inflammation associated with annular tears: Demonstration with gadolinium-enhanced lumbar spine MRI. Eur Spine J. 1999; 8 (1): 34-9.

108. Sasso R, Macadaeg K, Nordmann D, Smith M. Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging. J Spinal Disord Tech. 2005;18:471-478.

109. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: A prospective, randomized, double-blind clinical trial. Spine (Phila Pa 1976). 2009;34:1441-1447.

110. Schaufele M, Hatch L, Jones W. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician. 2006;9:361-366.

111. Shah RD, Cappiello D, Suresh S. Interventional procedures for chronic pain in children and adolescents: a review of the current evidence. World Institute of Pain. 2016: 359-369.

112. Shanthanna H, Busse JW, Thabane L, Paul J, Couban R, Choudhary H, Kaushal A, Suzumura E, Kim I, Harsha P. Local anesthetic injections with or without steroid for chronic non-cancer pain: a protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2016; 5:18.

113. Slipman C, Lipetz J, DePalma M, Jackson H. Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain. Am J Phys Med Rehabil. 2004; 83:446-454.

114. Slipman C, Lipetz J, Wakeshima Y, Jackson H. Nonsurgical treatment of zygopopheseal joint cyst-induced radicular pain. Arch Phys Med Rehabil 2000 Jul; 81(7): 973-7.

115. Southern D, Lutz GE, Cooper G, Barre L. Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain? Pain Physician 2003 Apr;6(2): 167-72.

116. Spijker-Huiges A, Vermeulen K, Winters JC, van Wijhe M, van der Meer K. Epidural steroids for lumbosacral radicular syndrome compared to usual care: quality of life and cost utility in general practice. Arch Phys Med Rehabil. 2015 Mar;96(3):381.

117. Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine 2009; 34(1):49.

118. Stout A. Epidural Steroid injection for low back pain. Phys Med Rehabil Clin N Am. 2010 Nov 21(4): 825 – 34.

119. Tafazal S, Ng L, Chaudhary N, Sell P. Corticosteroids in peri-radicular infiltration for radicular pain: A randomised double blind controlled trial: one year results and subgroup analysis. Eur Spine J. 2009;18:1220-1225.

120. Thomas E, Cyteval C, Abiad L, et al. Efficacy of transforaminal -versus interspinous corticosteroid injection in discal radiculalgia – A prospective, randomised, double-blind study. Clin Rheumatol.2003; 22:299-304.

121. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: A prospective randomized study. Spine (Phila Pa 1976) 2002; 27:11-16.

122. Valat J, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Pract Res Clin Rheumatol. 2010 Apr:24(2): 241-52.

123. Valat J, Giraudeau B, Rozenberg S, et al. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003;62:639-643.

124. Van Helvoirt H, Apeldoorn A, Ostelo R, Knol D, Arts M, Kamper S, van Tulder M. Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014 Jul; 15(7): 1100-8.

125. Wei G, Liang J, Chen B, Zhou C, Ru N, Chen J, Zhang F. Comparison of transforaminal verse interlaminar epidural steroid injection in low back pain with lumbosacral radicular pain: a meta-analysis of the literature. Int Orthop. 2016 Dec;40(12):2533-2545. Epub 2016 May 20.

126. Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br 2005; 87:352-355.

127. Woodward J, Herring S, Windsor R, ed. Lennard T. Epidural Procedures in Spine Pain Management. Pain Procedures in Clinical Paractice. Second Edition. Hanley and Belfus Inc. Philidelphia. 2000, page 359.

128. Zhai J, Zhang L, Li M, Tian Y, Zheng W, Chen J, Huang T, Li X, Tian Z. Epidural injection with or without steroid in managing chronic low back and lower extremity pain: A meta-analysis of ten randomized controlled trials. Int J Clin Exp Med. 2015;8(6):8304-8316.

129. Zhai J, Zhang L, Li M, Tian Y, Zheng W, Chen J, Huang T, Li X, Tian Z. Epidural injection with or without steroid in managing chronic low back and lower extremity pain: A meta-analysis of ten randomized controlled trials. Am J Ther. 2017 May;24(3):e259-e269.

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*

62320
62321
62322
62323
62324
62325
62326
62327
64479
64480
64483
64484
0228T
0229T
0230T
0231T