J3475, Injection, magnesium sulfate, per 500 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For repeat procedures beyond specified intervals (e.g., beyond 12 months), submission of clinical review documentation justifying continued treatment.
- For oncologic, infectious, or complex structural indications: relevant pathology/imaging reports, operative reports, prior treatments, and specialist consultation notes as applicable to demonstrate meeting of selection criteria.
- For inclusion in many interbody fusion device studies: failure of conservative care (commonly documented as unresponsive to at least 6 months of conservative care).
- For facet joint injections: documentation that member has symptoms suggestive of facet joint syndrome (absence of radiculopathy, pain aggravated by extension/rotation/lateral bending, not typically associated with neurological deficits), provocative testing on physical exam confirming facet mediated pain (pain exacerbated by extension and rotation), imaging studies ruling out other obvious causes (e.g., fracture, tumor, infection, significant extraspinal lesion), pain limits ADLs, pain duration > 3 months, and pain persisted despite ≥ 6 weeks of conservative treatment (systemic meds and/or PT).
Key Coverage Criteria
- Epiduroscopy / epidural lysis of adhesions: proposed for diagnosis/treatment of intractable LBP (including failed back surgery syndrome) by visualizing and lysing adhesions and injecting medications (insufficient high-quality evidence to support routine clinical use).
- Kyphoplasty (balloon-assisted vertebroplasty): restore bone height for painful osteoporotic compression fractures (OVCFs); NICE and other assessments note kyphoplasty may be a reasonable alternative to vertebroplasty for recent fractures.
- Sacropasty: injection of PMMA into sacrum for sacral insufficiency fractures (SIFs) in osteoporotic patients to stabilize fracture and relieve pain (developing indication).
- Vesselplasty: image-guided procedure using a containment device and PMMA to treat symptomatic vertebral compression fractures to reduce cement leakage (investigational/promise shown but limited evidence).
- Microsurgical anterior foraminotomy: proposed for intractable cervical radiculopathy to remove herniated disc or bone spur via anterior approach without fusion (insufficient high-quality evidence).
- Open sacroiliac fusion: proposed for SIJ dysfunction/syndrome when other non-operative treatments failed; evidence insufficient to support routine use.
7 Active Policies
AETNA-CPB-0462, Headaches: Nonsurgical Management
AETNA-CPB-0512, Premenstrual Syndrome and Premenstrual Dysphoric Disorder
AETNA-CPB-0468, Magnesium Sulfate Injections and Terbutaline Pump for Preterm Labor
AETNA-CPB-0374, Trigeminal Neuralgia: Treatments
AETNA-CPB-0016, Back Pain - Invasive Procedures
Related Codes
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