Local Coverage Determination for Epidural (L29165)

1 Local Coverage Determination (LCD) for Epidural (L29165)Contractor InformationContractor NameFirst Coast Service Options, Number09102 Contractor TypeMAC - Part BBack to TopLCD InformationDocument InformationLCD ID NumberL29165 LCD TitleEpiduralContractor's Determination Number62310 AMA CPT/ADA CDT Copyright StatementCPT codes, descriptions and other data onlyare copyright 2011 American MedicalAssociation (or such other date of publicationof CPT). All Rights Reserved. ApplicableFARS/DFARS Clauses Apply. Current DentalTerminology, (CDT) (including procedurecodes, nomenclature, descriptors and otherdata contained therein) is copyright by theAmerican Dental Association. 2002, 2004 American Dental Association. All rightsreserved. Applicable FARS/DFARS Geographic JurisdictionFloridaOversight RegionRegion IVOriginal Determination Effective DateFor services performed on or after 02/02/2009 Original Determination Ending DateRevision Effective DateFor services performed on or after 01/01/2012 Revision Ending DateCMS National Coverage PolicyLanguage quoted from CMS National Coverage Determination (NCDs) and coverageprovisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD).

2 NCDs and Coverage provisions in interpretive manuals are not subject to the LCDR eview Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, anadministrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social otherwise specified, italicized text represent quotation from one or more of thefollowing CMS sources:Change Request 7121, Transmittal 2037, dated August 27, 2010 Printed on 2/3/2012. Page 1 of 10 Indications and Limitations of Coverage and/or Medical NecessityEpidural injections are used for the treatment of multiple different conditions in chronic andacute pain. Epidural injections may be used for therapeutic and/or diagnostic are multiple approaches to Epidural injections including caudal, translaminar, andtransforaminal. These different approaches are used for different but specific indications.

3 (Ingeneral it is felt that the closer the injection can be placed to the pathology the more likely toachieve a beneficial response). Correct placement is best confirmed by using fluoroscopicguidance and injection of will consider Epidural injections and/or infusions medically reasonable andnecessary for the following conditions:1. Management of pain caused by intervertebral disc disease with or without Management of pain caused by spinal Management of intractable radicular pain due to postlaminectomy syndrome/failed Management of intractable pain due to complex regional pain Management of intractable pain due to post herpetic neuralgia and acute herpes Management of intractable pain due to traumatic neuropathy of the spinal nerve Management of intractable and severe pain secondary to neuropathy from other causes( , diabetic or metabolic).

4 8. Management of severe, intractable pain in patients with advanced stages of cancer withestimated life expectancy of 4 months or Management of pain caused by radiculitis (inflammation of the nerve roots).Low back pain may also be produced by Myofascial Pain Syndrome in which case there isnot nerve root pathology and Epidural injections are not reasonable and necessary. If there isa doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by anEMG/nerve conduction/small fiber testing or appropriate radiological study. DegenerativeDisk Disease without root compression has been shown to be a significant cause of low backand/or radicular pain; some patients will respond to Epidural Steroid Injection in this injections, regardless of the approach used, should be performed under fluoroscopicor CT-guided imaging.

5 Therefore, injections for chronic pain performed without imagingguidance are considered not medically reasonable or to TopCoding InformationPrinted on 2/3/2012. Page 2 of 10 Bill Type Codes:Contractors may specify Bill Types to help providers identify those Bill Types typically used toreport this service. Absence of a Bill Type does not guarantee that the policy does not applyto that Bill Type. Complete absence of all Bill Types indicates that Coverage is not influencedby Bill Type and the policy should be assumed to apply equally to all Codes:Contractors may specify Revenue Codes to help providers identify those Revenue Codestypically used to report this service. In most instances Revenue Codes are purely advisory;unless specified in the policy services reported under other Revenue Codes are equallysubject to this Coverage Determination .

6 Complete absence of all Revenue Codes indicatesthat Coverage is not influenced by Revenue Code and the policy should be assumed to applyequally to all Revenue ApplicableCPT/HCPCS CodesGroupNameFor Single Injection62310 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S)(INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID,OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES,INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDESCONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURALOR SUBARACHNOID; CERVICAL OR THORACIC62311 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S)(INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID,OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES,INCLUDING NEEDLE OR CATHETER PLACEMENT, INCLUDESCONTRAST FOR LOCALIZATION WHEN PERFORMED, EPIDURALOR SUBARACHNOID; LUMBAR OR SACRAL (CAUDAL)GroupNameFor Transforaminal Epidural Injections64479 INJECTION, ANESTHETIC AGENT AND/OR STEROID,TRANSFORAMINAL Epidural , WITH IMAGING GUIDANCE(FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL64480 INJECTION, ANESTHETIC AGENT AND/OR STEROID,TRANSFORAMINAL Epidural , WITH IMAGING GUIDANCE(FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACHADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODEFOR PRIMARY PROCEDURE)64483 INJECTION, ANESTHETIC AGENT AND/OR STEROID,TRANSFORAMINAL Epidural , WITH IMAGING GUIDANCE(FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL64484 Printed on 2/3/2012.

7 Page 3 of 10 INJECTION, ANESTHETIC AGENT AND/OR STEROID,TRANSFORAMINAL Epidural , WITH IMAGING GUIDANCE(FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONALLEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARYPROCEDURE)ICD-9 Codes that Support Medical ZOSTER WITH UNSPECIFIED NERVOUS ZOSTER ZOSTER WITH OTHER NERVOUS - NEOPLASM OF NASAL CAVITIES - MALIGNANTNEOPLASM OF ILL-DEFINED SITES WITHIN THE - NEOPLASM OF BONES OF SKULL AND FACE EXCEPTMANDIBLE - KAPOSI'S SARCOMA UNSPECIFIED SITE179 - NEOPLASM OF UTERUS-PART UNS - MALIGNANTNEOPLASM OF URINARY ORGAN SITE - NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVACORNEA RETINA AND CHOROID - MALIGNANT NEOPLASMASSOCIATED WITH TRANSPLANT - UNSPECIFIED SITE - UNSPECIFIEDLEUKEMIA, IN - CARCINOID TUMOR OF THE SMALL INTESTINE,UNSPECIFIED PORTION - BENIGN CARCINOID TUMOR OF - NEUROENDOCRINE TUMOR.

8 UNSPECIFIED SITE -SECONDARY NEUROENDOCRINE TUMOR OF OTHER - NEOPLASM OF LIP - BENIGN NEOPLASM OF - IN SITU OF LIP ORAL CAVITY AND PHARYNX -CARCINOMA IN SITU SITE - OF UNCERTAIN BEHAVIOR OF MAJOR SALIVARYGLANDS - NEOPLASM OF UNCERTAIN BEHAVIOR OF UNSPECIFIED NATURE OF DIGESTIVE OF UNSPECIFIED NATURE OF RESPIRATORY OF UNSPECIFIED NATURE OF BONE SOFT TISSUEAND OF UNSPECIFIED NATURE OF OF UNSPECIFIED NATURE OF BLADDERP rinted on 2/3/2012. Page 4 of 10 OF UNSPECIFIED NATURE OF OTHERGENITOURINARY OF UNSPECIFIED NATURE OF OF UNSPECIFIED NATURE OF ENDOCRINE GLANDSAND OTHER PARTS OF NERVOUS OF UNSPECIFIED NATURE, OTHER SPECIFIED OF UNSPECIFIED NATURE SITE WITH NEUROLOGICAL MANIFESTATIONS, TYPE II ORUNSPECIFIED TYPE, NOT STATED AS WITH NEUROLOGICAL MANIFESTATIONS, TYPE I[JUVENILE TYPE], NOT STATED AS - CEREBRAL PALSY - OTHER ACQUIRED SPASTIC DISEASE OF SPINAL AUTONOMIC NEUROPATHY IN DISORDERSCLASSIFIED - SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEXSYMPATHETIC DYSTROPHY OF OTHER SPECIFIED - PAIN DUE TO TRAUMA - OTHER ACUTE PAIN DUE TO POST-THORACOTOMY CHRONIC RELATED PAIN (ACUTE) (CHRONIC)

9 PAIN SYNDROME340 MULTIPLE - HEMIPLEGIA AND HEMIPARESIS AFFECTINGUNSPECIFIED SIDE - SPASTIC HEMIPLEGIA AND HEMIPARESISAFFECTING NONDOMINANT - DIPLEGIA - INFANTILE CEREBRAL SPECIFIED PARALYTIC PLEXUS PLEXUS ROOT LESIONS NOT ELSEWHERE ROOT LESIONS NOT ELSEWHERE ROOT LESIONS NOT ELSEWHERE LIMB (SYNDROME)Printed on 2/3/2012. Page 5 of 10 - TUNNEL SYNDROME - MONONEURITIS OF UPPER OF MEDIAL POPLITEAL - OF LOWER LIMB - OTHER MONONEURITIS OF IDIOPATHIC PERIPHERAL - IN COLLAGEN VASCULAR DISEASE -POLYNEUROPATHY IN OTHER DISEASES DUE TO DUE TO OTHER TOXIC - INFLAMMATORY DEMYELINATING POLYNEURITIS -OTHER INFLAMMATORY AND TOXIC OF CERVICAL INTERVERTEBRAL DISC OF LUMBAR INTERVERTEBRAL DISC OF THORACIC INTERVERTEBRAL DISC OF CERVICAL INTERVERTEBRAL OF THORACIC OR THORACOLUMBARINTERVERTEBRAL OF LUMBAR OR LUMBOSACRALINTERVERTEBRAL DISC DISORDER WITH MYELOPATHY DISC DISORDER WITH MYELOPATHYTHORACIC DISC DISORDER WITH MYELOPATHY SYNDROME OF CERVICAL SYNDROME OF THORACIC SYNDROME OF LUMBAR - STENOSIS IN CERVICAL REGION - UNSPECIFIEDMUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLETO - STENOSIS OF

10 UNSPECIFIED REGION - OTHERUNSPECIFIED BACK FRACTURE OF - PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHERSPECIFIED EFFECT OF SPINAL CORD INJURYP rinted on 2/3/2012. Page 6 of 10 TO CERVICAL NERVE TO DORSAL NERVE TO LUMBAR NERVE TO SACRAL NERVE TO BRACHIAL TO LUMBOSACRAL TO MULTIPLE SITES OF NERVE ROOTS AND *LONG-TERM (CURRENT) USE OF ANTICOAGULANTS* Use only as a supplemented code in addition to the primary diagnosis, when anticoagulanttherapy has been temporarily discontinued to facilitate therapeutic injections for that Support Medical NecessityN/AICD-9 Codes that DO NOT Support Medical NecessityN/AXX000 Not ApplicableICD-9 Codes that DO NOT Support Medical Necessity Asterisk ExplanationDiagnoses that DO NOT Support Medical NecessityN/ABack to TopGeneral InformationDocumentations RequirementsMedical necessity for providing the service must be clearly documented in the patient s medical recordand submitted upon request for of the outcome of this procedure depends on the patient s responses, thereforedocumentation should include.