72275
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Discography: Documentation of absence of red flag conditions (see General Guidelines).
- Discography: Documentation of at least 6 weeks of conservative therapy with specifics (NSAIDs and/or muscle relaxants; conservative self-care or prescribed physical therapy/core strengthening program) and that such therapy produced less than clinically meaningful improvement.
- Discography: Documentation of pain pattern and physical examination findings suggesting disc disease (subacute axial pain >12 weeks; axial pain worsening with upright posture; absence of radicular pain; absence of trigger points; absence of sacroiliac joint dysfunction).
- Discography: Documentation that facet joint disease has been evaluated and ruled out.
Key Coverage Criteria
- Discography is considered medically necessary as a provocative diagnostic test for axial pain when all of the following are met: Absence of red flag conditions; Less than clinically meaningful improvement for at least 6 weeks which includes both NSAIDS and/or muscle relaxants AND conservative self-care (muscle stretching, over the counter medications, regular exercise) or prescribed physical therapy core strengthening program; Pain pattern and/or physical examination suggesting disc disease as e [...]
- Post-discography CT scan is automatically approved as an add-on to discography.
- Spinal fluoroscopy: Fluoroscopic imaging guidance is medically necessary when all of the following are met: Performed with a spinal or paraspinal diagnostic or therapeutic injection procedure; Placement of needle or catheter at the neural structure cannot be adequately performed without image guidance; Imaging guidance is not included in the planned procedure(s).
- Greater occipital nerve block: The performance of the first greater occipital nerve block for occipital neuralgia is medically necessary when all of the following are met: Absence of red flag conditions; Diagnosis of occipital neuralgia as evidenced by both of the following: Paroxysmal stabbing pain, with or without aching between attacks, in the distribution of the nerve; Tenderness over the affected nerve; Evidence of a comprehensive headache evaluation with consideration of alternative causes [...]
- Greater occipital nerve block: The performance of the second and subsequent greater occipital nerve block(s) for recurrent occipital neuralgia is medically necessary when all of the following are met: Absence of red flag conditions; Significant improvement after first injection; Self-care is attempted at headache onset and ineffective and includes both anti-inflammatory medications or muscle relaxants AND rest, massage, or heat; Confirmed diagnosis of recurrent occipital neuralgia as evidenced b [...]
- Creation of lesion by neurolytic agent (for trigeminal neuralgia): Initial lesion is medically necessary when all of the following are met: History, signs, and symptoms include recurrent, severe, unilateral, shock-like pain in the forehead, and/or face, and/or jaw AND there is a diagnosis of trigeminal neuralgia with evidence of consideration of alternative diagnoses; Imaging including either MRI demonstrating absence of an intracranial mass or multiple sclerosis OR if MS/intracranial mass prese [...]
2 Active Policies
EVICORE-MSK_ADVANCED-4D1D2A14 — CMM-404: Epidurography
EVICORE-MSK_ADVANCED-877D81E9 — Addendum to eviCore Guidelines
Related Codes
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