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Aetna considers the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only 1 invasive modality or procedure will be considered medically necessary at a time.  Epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, are considered medically necessary in the outpatient setting for management of persons with radiculopathy or sciatica when all of the following are met: 1. Intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out as the cause of pain; and 2. Member has failed to improve after 2 or more weeks of conservative measures (e.g., rest, systemic analgesics and/or physical therapy); and 3. Epidural injections beyond the first set of 3 injections are provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate. Epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications (e.g., non-specific low back pain [LBP] and failed back syndrome) because their effectiveness for indications other than the ones listed above has not been established. Repeat epidural injections beyond the first set of 3 injections are considered medically necessary when provided as part of a comprehensive pain management program, which includes physical therapy, patient education, psychosocial support, and oral medications, where appropriate. Repeat epidural injections more frequently than every 7 days are not considered medically necessary. Up to 3 epidural injections are considered medically necessary to diagnose a member's pain and achieve a therapeutic effect; if the member experiences no pain relief after three epidural injections, additional epidural injections are not considered medically necessary. Once a therapeutic effect is achieved, it is rarely medically necessary to repeat epidural injections more frequently than once every 2 months. In selected cases where more definitive therapies (e.g., surgery) can not be tolerated or provided, additional epidural injections may be considered medically necessary. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity. CPT Codes / ICD-9 Codes / HCPCS Codes
CPT codes covered if selection criteria are met: Other CPT codes related to the Clinical Policy Bulletin: Other HCPCS codes related to the Clinical Policy Bulletin:  J1020 — Injection, methylprednisone acetate, 20 mg  J1030 — Injection, methylprednisone acetate, 40 mg  J1040 — Injection, methylprednisone acetate, 80 mg ICD-9 codes covered if selection criteria are met:  723.1 — Cervicalgia [see criteria]  723.2 — Cervicocranial syndrome [see criteria]  723.8 — Other syndromes affecting cervical region [see criteria]  724.1 — Pain in thoracic spine [see criteria]  724.5 — Backache, unspecified [see criteria] ICD-9 codes not covered for indications listed in the Clinical Policy Bulletin:  170.2 — Malignant neoplasm of vertebral column, excluding sacrum and coccyx  170.6 — Malignant neoplasm of pelvic bones, sacrum, and coccyx  192.2 — Malignant neoplasm of spinal cord  192.3 — Malignant neoplasm of spinal meninges  198.3 — Secondary malignant neoplasm of brain and spinal cord  198.4 — Secondary malignant neoplasm of other parts of nervous system  198.5 — Secondary malignant neoplasm of bone and bone marrow  213.2 — Benign neoplasm of vertebral column, excluding sacrum and coccyx  213.6 — Benign neoplasm of pelvic bones, sacrum, and coccyx  225.3 — Benign neoplasm of spinal cord  225.4 — Benign neoplasm of spinal meninges  237.5 — Neoplasm of uncertain behavior of brain and spinal cord  237.6 — Neoplasm of uncertain behavior of meninges  239.7 — Neoplasm of unspecified nature of endocrine glands and other parts of nervous

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