PARTNERSHIP HEALTHPLAN OF CALIFORNIA
Medical Necessity Criteria for Pain Management Procedures
MCUG3007 - Attachment C
MCUP3049 – Attachment B
11/18/14
22521 to 22525 Percutaneous vertebroplasty
and percutaneous vertebral augmentation
27096 SI joint injection
62290 to 62291 Discography, Lumbar and
Cervical
62360 to 62362 Implantable or replacement
device for intrathecal or epidural drug infusion;
subcutaneous reservoir
63650 thru 63688 Insertion, revision, or
removal of spinal neurostimulator
64479 to 64484 Transforaminal epidural
injection
Recent well controlled study shows no benefit over
placebo for longstanding vertebral fractures/pain.
Evidence not as clear for acute fracture; as such,
approval will only be considered in patients with 1.
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), or 2. Vertebral hemangioma failing
conservative therapy, or 3. Malignancy related
compression fracture with no neurologic symptoms and
pain interfering with activities of daily living. (Same as
InterQual criteria, except that longstanding fracture not
covered; 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)
Remove requirement for trial of NSAIDs and imaging
studies. Activity 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. (Same as previous criteria,
except documentation requirements removed)
Current 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)
Only medical indication that will be covered is
intractable pain caused by malignancy, where a
randomized controlled trial has shown short and longterm benefit. Studies in non-cancer pain are
observational and of poor quality. (Reference: Pain
Physician. 2011 May-Jun; 14(3): 219-248)
InterQual criteria followed (covered for complex regional
pain syndrome, failed back surgery) except that
requirement for psychiatric evaluation is waived except
in patients with serious mental illness.
Same as InterQual except: remove requirement for
documentation of trial of NSAIDS; add requirement for
progress note to demonstrate history of radicular
PARTNERSHIP HEALTHPLAN OF CALIFORNIA
Medical Necessity Criteria for Pain Management Procedures
MCUG3007 - Attachment C
MCUP3049 – Attachment B
11/18/14
64490 to 64495 Paravertebral facet injections
and medial branch blocks
64633 to 64636 Destruction by neurolytic
agent, paravertebral facet joint
72285, 72295 Cervical, Thoracic, Lumbar
discography
symptoms. A minimum of 30 days conservative
treatment before eligible for epidural steroid injection.
If MRI shows spinal stenosis with no significant
impingement, epidural injection is not medically
indicated. For repeat injections, a minimum of 50%
improvement in pain symptoms on the prior epidural
injection is required. Maximum of two levels of
transforaminal epidural injections of the spine per 3
months. This may be two levels on the same side or one
level bilaterally. The interval between injections must be
no more frequently than every 2 months, and the
maximum number of injections per site is three per year.
Initial 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 4 levels will be approved,
either 4 levels on one side or two levels bilaterally.
Maximum of two MBB per level per year. For repeat
injections, a pain log must be submitted showing that
the pain relief was consistent with the anesthetic agent
used. For example, for a pure bupivacaine block, this is
about 2-3 hours; bupivacaine plus minimal dose steroid
block could be up 3-4 days for medial branch blocks
versus a month to several months for facet joint block.
InterQual criteria followed
Same as 62290 and 62291 above.