Addendum to Musculoskeletal Management Guidelines

This Evicore addendum deems discography, greater occipital nerve blocks, neurolytic lesioning, epidurography, spinal fluoroscopy and related musculoskeletal procedures medically necessary only when strict, procedure-specific criteria are met and excludes procedures performed in the presence of red flags, investigational/unproven procedures (e.g., functional anesthetic discography, chemonucleolysis, occipital nerve ablation), procedures lacking required imaging guidance, or those violating specified timing/frequency limits. Key requirements include documented absence of red flags, procedure-specific diagnostic signs and imaging (e.g., annular tears/contained herniation/HIZ for discography; MRI excluding intracranial mass/MS for neurolysis), prior conservative therapy durations (e.g., ≥6 weeks of NSAIDs/muscle relaxants plus self‑care or PT for discography), prior pharmacologic trials for trigeminal neuralgia, imaging guidance (fluoroscopy/CT) for interventions, detailed clinical/radiologic documentation and opioid co‑management plans for chronic opioid users, plus limits such as ≤6 greater occipital nerve blocks/year and ≥4 weeks between certain cervical/head injections; note discography is not considered medically necessary if not coincident with discectomy or not performed by both the surgeon and a supervising radiologist.