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Aetna considers any of 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. These may be performed bilaterally during the same session for a total of up to six injections. A second diagnostic facet injection intraarticular and medial branch block is considered medically necessary to confirm the validity of the clinical response to the initial facet injection when it is administered at the same level as the initial facet injection, and where the initial facet injection produced a positive response i.
If the initial injection did not produce a positive response, a second diagnostic injection is considered not medically necessary.
Diagnostic facet joint injections are considered experimental and investigational for neck and back pain with untreated radiculopathy. Facet joint injections are considered experimental oak dowel shear strength pdf investigational as therapy for back and neck pain and sstrength all other indications because their effectiveness for these indications has not been established.
Facet joint oak dowel shear strength pdf intra-articular and medial branch blocks containing corticosteroids are considered therapeutic strengthh.
Aetna considers diagnostic facet joint injections not medically necessary where radiofrequency facet neurolysis is not being considered. Additional sets of facet injections or medial branch blocks at the same levels and side are considered experimental and investigational because they have no proven value. Aetna considers ultrasound guidance of facet injections experimental and investigational because of insufficient evidence of its effectiveness.
Trigger point injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above zhear not been established.
Aetna considers ultrasound or electromyography EMG guidance of trigger point injections experimental and investigational because of insufficient evidence of its effectiveness. A trigger point is defined as a specific point or area where, if stimulated by touch or pressure, a painful response will be induced. A set of trigger point injections means injections in several trigger points in one sitting. It is not considered medically ldf to repeat injections more frequently than every 7 days.
Up to 4 sets of injections are considered medically necessary to diagnose the origin of a patient's pain and achieve a therapeutic effect; additional sets of trigger point injections are not considered medically necessary if no clinical response is achieved.
Once a diagnosis is established and a therapeutic effect is achieved, it is rarely considered medically necessary to repeat trigger point injections more frequently than once every 2 months. Repeated injections extending beyond 12 months may be reviewed for continued medical necessity. Aetna considers dry needling experimental and investigational for the treatment of low back pain because the effectiveness of this approach has not been established.
Sacroiliac joint injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above srrength not been established.
Up to 2 diagnostic sacroiliac injections are considered medically necessary to diagnose oak dowel shear strength pdf member's pain and achieve a therapeutic effect. It is not considered medically necessary to repeat these injections more frequently than once every 7 days. Once oqk diagnosis is established, up to four therapeutic sacroiliac injections are considered medically necessary every 12 months.
Ultrasound guidance of sacroiliac joint injections is considered not medically necessary. Interlaminar epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications e. Oak dowel shear strength pdf interlaminar epidural injections are considered medically necessary if the initial injection resulted in at least oak dowel shear strength pdf of the following for at least two weeks:.
Additionally, when medical necessity criteria are met for an initial or repeat cervical or thoracic interlaminar epidural oak dowel shear strength pdf injections, advanced diagnostic imaging should be performed within 24 months prior to the initial or repeat injection. Aetna considers ultrasound guidance of epidural injections experimental and investigational because of insufficient evidence of its effectiveness.
Chymopapain chemonucleolysis is considered experimental and investigational for all other indications, including the following because its effectiveness for these indications oak dowel shear strength pdf not been established:.
Percutaneous lumbar diskectomy is oak dowel shear strength pdf experimental and investigational for all other indications because its effectiveness for indications other than the one listed above has not been established. Note : Clinical studies have not established any clinically significant benefit of use of a laser over use of a scalpel for percutaneous lumbar diskectomy.
Non-pulsed radiofrequency facet denervation is considered experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established. Only 1 treatment procedure per level per side is considered medically necessary in a 6-month period. Pedicle screw fixation is considered experimental and investigational for all other indications, including the following because its effectiveness for indications other than the ones listed above has not been established:.
Cervical corpectomy removal of half or more of vertebral body, not mere removal of osteophytes and minor decompression in the treatment of one of the following:. Spine cages are otherwise not considered medically necessary for cervical fusion because oak dowel shear strength pdf have not been proven more effective than bone graft for this indication.
Spine cages are considered experimental and investigational for indications other than fusion because their effectiveness for indications other than those listed above has not been established. Expandable cages are considered medically necessary for persons who meet criteria for fusion in CPB sheaf Spinal Shexr Laminectomy and Fusion and who meet either of the following criteria:.
For "cementoplasty" for vertebral indications, see section on vertebroplasty. Other causes of low back pain have been ruled out, including lumbar disc degeneration, lumbar disc herniation, lumbar spondylolisthesis, lumbar spinal stenosis, lumbar facet degeneration, and shrength vertebral body fracture. Open sacroiliac joint fusion is considered medically necessary for sacroiliac joint infection, hsear involving the sacrum, and sacroiliac pain due to severe traumatic injury where a trial of an external strengtn is successful in providing pain relief.
Sacroiliac joint fusions are considered experimental and investigational for all other indications because their oak dowel shear strength pdf for indications other than the ones listed above has not been established. Aetna considers any of the following injections or procedures experimental and investigational:.
Clinical studies have not established a clinically significant benefit of use of a laser over a scalpel in spinal surgery. No additional benefit will be provided for the use of a laser in spinal surgery. Use of a microscope or endoscope is considered an integral part of the spinal surgery and not separately reimbursable.
An epidural steroid finjection is an injection of long lasting steroid in the epidural space — that is the area which surrounds the spinal cord and the nerves coming out of it. An epidural steroid injection is used to help reduce radicular spinal pain that may be caused by pressure oak dowel shear strength pdf a spinal nerve root as a result of a herniated disc, dowe disc disease or spinal stenosis. This treatment is most frequently used for low back pain, though it may also be used for cervical neck or thoracic midback pain.
A combination of an anesthetic and a steroid medication is injected into the epidural space near the affected spinal nerve root with the assistance of fluoroscopy which allows the physician to view the placement of the needle. This approach is commonly used to treat lumbar radiculopathy after prior surgery in the low back post-laminectomy pain syndrome. Also called translaminar, this method accesses the large epidural space overlying the spinal cord, and is the most commonly used approach for cervical, thoracic, and lumbar epidural injections.
Medication is delivered to the nerve roots on both the right and left sides of the inflamed area at the same time.
The goal of this treatment is to reduce inflammation and block the spinal nerve roots to relieve radicular pain or sciatica. It can also provide sufficient pain relief to allow the individual to progress with their rehabilitation program. The efficacy of epidurally administered steroids has been demonstrated without adverse consequence in a large number of patients with reproducible results. Strdngth for cervical pain are somewhat lower strengfh those for lumbar dwel. Such therapy is considered under accepted guidelines to be indicated in patients with low back and cervical pain that has not resolved after only a short period of more conservative measures since studies have shown a better response to therapy in patients whose pain is of shorter duration.
Even if pain relief is temporary, it may have long-term benefit because it allows initiation of physical therapy or other rehabilitative measures at an earlier stage. Most authors indicate that a limit on number of injections is oqk, and that most patients will respond with 3 or fewer injections.
The American Academy of Neurology's assessment on the use of epidural steroid injections in oak dowel shear strength pdf treatment of radicular lumbosacral pain Armond et al, concluded that:. Guidelines from the American Pain Society Chou et al, questioned the clinical value of epidural injection for long-term use or for use of non-radicular back pain. A recommendation for epidural steroid injection for patients oak dowel shear strength pdf symptomatic spinal stenosis was not offered based on insufficient or poor evidence.
Trigger point injections TPI are injections of saline or a local anesthetic, with or without a steroid medication, into a painful area of a muscle that contains the trigger point. The oak dowel shear strength pdf of a TPI is to relax the area of intense muscle spasm, effectively inactivate the trigger point and provide prompt symptomatic pain pvf.
TPI is oak dowel shear strength pdf most common interventional technique used in pain medicine. Trigger Oak Dowel Shear Strength points have also been treated with dry needling. Dry needling is not to be confused with traditional Chinese acupuncture, even though it does make use of acupuncture-type needles. Acupuncture follows the principles of energy flow as a guide to where the needles will be inserted; in dry needling, needles are inserted directly into a myofascial trigger point, in an attempt to inactivate it, thereby decreasing the associated pain.
Dry needling, even though it targets a trigger point, also differs from a trigger point injection, as there is no injection of medication or fluid. A myofascial trigger point is a discrete focal tenderness, mm in diameter that is located in distinct tight bands or knots of skeletal muscle Oa, When palpated, these hyper-irritable areas cause pain in distant strenght, or referred pain zones, which are specific for each trigger point.
Trigger point injection, or direct wet needling, involves injection of fluid directly into the trigger point located in the taut muscle band. The main objective of trigger point injection is fast pain relief and elimination of muscle spasm in order to break the pain cycle.
This facilitates physical therapy aimed at reducing muscle contracture and increasing range of motion. Trigger point injection is rarely oak dowel shear strength pdf in isolation but is generally part of a multi-disciplinary approach aimed at treating both oal trigger points and reducing all contributing factors Scott and Guo, ; AHFMR, ; Sanders et al, Thus, treatment may also include patient education, psychosocial support, oral medications, and physical therapy to improve the strength and flexibility of the affected musculoskeletal systems.
An assessment conducted by the Alberta Heritage Foundation for Medical Research Scott and Guo, found that the evidence for the effectiveness of trigger point injections when used as the sole treatment for patients with chronic head, neck, and shoulder strengtn and whiplash syndrome was inconclusive, regardless of whether sterile water, saline, or botulinum toxin is injected.
The assessment found that the combined use of dry needling and trigger point injection with procaine offers no obvious clinical benefit in the treatment of chronic craniofacial pain, while the effectiveness of trigger point injection for the treatment of cervicogenic headache is unknown.
In contrast, the assessment found that trigger point injection with lidocaine may be useful in the treatment of joint pain caused by osteoarthritis Scott and Guo, The assessment found no proof dwel triggers point suear is more effective than other less invasive treatments, such as physical therapy and ultrasound, in achieving pain relief, oak dowel shear strength pdf there is some suggestion that the only advantage of injecting anesthetic into trigger Oak Dowel Shear Strength Index points is that it reduces the pain of the needling process Scott and Guo, A number of trigger points may be injected in 1 session, but rarely more than 5.
Repeated injections in a particular muscle are not recommended if 2 or 3 previous attempts have been unsuccessful Alvarez and Rockwell, ; Sanders et al, The pain relief may last for the duration of the anesthetic to many months, depending on the chronicity and severity of the trigger points and the concomitant treatment of perpetuating factors.
According to available guidelines, use of trigger point injections should be short-term and part stength a comprehensive rehabilitation program. Available guidelines indicate that, while there are a number of uncontrolled case studies using trigger point injections in more acute pain presentations, there is virtually no consistent evidence for its application with chronic non-malignant pain syndrome patients to date Sanders et al, ; AHFMR, Botwin and colleagues noted that myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle.
It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under diagnosed and under treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain which is responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and oak dowel shear strength pdf efficacy of the trigger point injection to help reduce or relieve myofascial pain.
In obese patients, these injections may not reach the target tissue. In oak dowel shear strength pdf cervico-thoracic spine, a misguided or misplaced injection can result in a pneumothorax. These researchers described an ultrasound-guided trigger point injection technique to avoid this potential pitfall. Office based ultrasound-guided injection techniques for musculoskeletal disorders have been described in the literature with regard to tendon, bursa, cystic, and joint pathologies.
For the interventionalist, utilizing ultrasound yields multiple advantages technically and practically, including observation of needle placement in real-time, ability to perform dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation exposure, reduced overall cost, and portability of equipment within the oak dowel shear strength pdf setting.
A palpable trigger point oak dowel shear strength pdf the cervico-thoracic musculature was localized and marked by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped. Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervico-thoracic spine where the palpable trigger point was detected was visualized.
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