It was six years ago in April 2009 that Noridian released a draft LCD touching off a furor over the effectiveness of paravertebral facet joint injections in treating lumbar back pain. The LCD would have eliminated coverage for lumbar paravertebral facet joint injections, facet joint nerve blocks and denervation procedures (2009 CPT codes 64622, 64623, 64475 and 64476).
At the time, Noridian said its action was based on literature, conflicting research results and Agency for Healthcare Research and Quality (AHRQ) guidance against facet injections for low back pain. In a recommendation, AHRQ had stated that “no evidence exists to support the effectiveness of facet injections in the treatment of patients with chronic low-back pain”.
Another factor influencing Noridian’s decision was inconsistency in the use of facet injections by providers, which may have contributed to the inconclusive or negative research results. Noridian medical directors cited a 2008 report from HHS Office of the Inspector General (OIG) which stated that 63% of facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments. The report also stated that 35% of Medicare facet joint injections were performed by non-interventional pain physicians.
Following an out roar from the interventional pain community and its associations, Noridian backtracked almost a year later when it rescinded the proposal for non-coverage and issued a new draft LCD retaining coverage of lumbar facet blocks but incorporating stricter requirements for proof of medical necessity. This settled the immediate controversy over lumbar spine injections. However, doubt about the procedures simmered on as CMS continued ongoing reviews of research into their effectiveness.
Lumbar spine injections received support at the state level this winter when the Health Technology Clinical Committee of the Washington State Health Care Authority, in a March 2016 hearing, took the issue under consideration and decided to continue coverage of the spinal injections for its Medicaid beneficiaries as well as workers covered under the Washington workers compensation program.
The Health Technology Committee’s decision is significant nationally because of its potential influence on other states’ decisions regarding the back pain injections.
In response, the American Society of Anesthesiologists issued a statement advancing the treatment’s effectiveness. It stated: “Maintaining access to spinal injection therapies can provide patients with the significant benefits of pain relief, improved function and quality of life, reducing their need for surgery or opioids, which is particularly important in the light of the national opioid abuse epidemic.”
The Health Technology Committee decision followed a strong lobbying effort by an organization known as the Multi-Society Pain Workgroup (MPW), which represents over 100,000 doctors and 15 medical societies.
“The collaborative effort and voices of more than 100,000 multidisciplinary pain specialists was heard loud and clear,” said Paul Dreyfuss, MD, who is a former chair of the MPW and who, as a clinical professor from the University of Washington School of Medicine in Seattle, lectured at the hearing on the procedures’ benefits.