Aetna · Clinical coverage policy

Aetna Back Pain - Invasive Procedures coverage criteria

Aetna CPB 0016 covers invasive procedures for back and neck pain — including diagnostic facet, trigger point, sacroiliac, and interlaminar epidural injections, non-pulsed radiofrequency facet denervation, various spinal fusion/fixation hardware and interbody devices, vertebroplasty/kyphoplasty, coccygectomy, and minimally invasive SI joint fusion — only when strict, procedure-specific gates are met: documented diagnosis, prior failure of weeks-to-months of conservative therapy, supporting imaging, and (for injections) a demonstrated prior response such as at least 70-80% pain relief. A large number of newer or alternative techniques and devices (e.g., dynamic stabilization, endoscopic/percutaneous discectomy, basivertebral nerve ablation, SI joint radiofrequency denervation, annular repair, ultrasound/EMG injection guidance) are deemed experimental, investigational, or unproven and are not covered.

Policy CPB 0016 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0016

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0016 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Back Pain - Invasive Procedures (CPT 22513), and what gets it denied?

Path
Aetna CPB 0016 covers invasive procedures for back and neck pain — including diagnostic facet, trigger point, sacroiliac, and interlaminar epidural injections, non-pulsed radiofrequency facet denervation, various spinal fusion/fixation hardware and interbody devices, vertebroplasty/kyphoplasty, coccygectomy, and minimally invasive SI joint fusion — only when strict, procedure-specific gates are met: documented diagnosis, prior failure of weeks-to-months of conservative therapy, supporting imaging, and (for injections) a demonstrated prior response such as at least 70-80% pain relief. A large number of newer or alternative techniques and devices (e.g., dynamic stabilization, endoscopic/percutaneous discectomy, basivertebral nerve ablation, SI joint radiofrequency denervation, annular repair, ultrasound/EMG injection guidance) are deemed experimental, investigational, or unproven and are not covered. Coverage criteria include: FACET JOINT INJECTIONS — Initial diagnostic facet injection (intra-articular and medial branch block) for diagnosis of facet pain in persons with severe chronic neck and back pain, medically necessary when ALL of: (a) symptoms suggestive of facet joint syndrome (absence of radiculopathy, pain aggravated by extension/rotation/lateral bending of spine, not typically associated with neurological deficits); AND (b) facet-mediated pain confirmed by provocative testing on physical exam (pain exacerbated by extension and rotation); AND (c) imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion); AND (d) pain limits daily activities; AND (e) pain has lasted more than 3 months; AND (f) pain has persisted despite six or more weeks of conservative treatment (including systemic medications and/or physical therapy); AND (g) radiofrequency facet neurolysis is being considered.; FACET JOINT INJECTIONS — Injection parameters: no more than three (3) facet joint levels considered medically necessary during the same session/procedure; may be performed bilaterally during the same session for a total of up to six injections.; FACET JOINT INJECTIONS — Second diagnostic facet injection medically necessary to confirm validity of clinical response to the initial facet injection when ALL of: (a) administered at the same level as the initial facet injection; AND (b) the initial facet injection produced a positive response (at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic effect). If the initial injection did not produce a positive response, a second diagnostic injection is NOT medically necessary.; TRIGGER POINT INJECTIONS — Medically necessary for treating members with chronic neck or back pain or myofascial pain syndrome when ALL of: (a) conservative treatment (bed rest, exercises, heating/cooling modalities, massage, pharmacotherapies such as NSAIDs, muscle relaxants, non-narcotic analgesics) has been tried and failed; AND (b) symptoms have persisted for more than 3 months; AND (c) trigger points identified by palpation; AND (d) trigger point injections not administered in isolation, but provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medication where appropriate.; TRIGGER POINT INJECTIONS — Injection parameters: up to 4 sets of injections medically necessary to diagnose origin of pain and achieve therapeutic effect; additional sets NOT medically necessary if no clinical response achieved; NOT medically necessary to repeat more frequently than every 7 days; once diagnosis established and therapeutic effect achieved, rarely medically necessary to repeat more frequently than once every 2 months; repeated injections extending beyond 12 months may be reviewed for continued medical necessity.; SACROILIAC JOINT INJECTIONS — Initial therapeutic/diagnostic SI injections medically necessary to relieve pain associated with lower lumbosacral disturbances when ALL of: (a) member has SI joint (SIJ) pain for greater than 3 months; AND (b) member has pain at or close to the posterior superior iliac spine (PSIS) with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (c) member has at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (d) other causes of low back pain ruled out, including lumbar disc degeneration, lumbar disc herniation, lumbar spondylolisthesis, lumbar spinal stenosis, lumbar facet degeneration, and lumbar vertebral body fracture; AND (e) member tried 6 weeks of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and active therapy (including physical therapy where appropriate); AND (f) injections not used in isolation but provided as part of a comprehensive pain management program including physical therapy, education, psychosocial support, and oral medication where appropriate.; SACROILIAC JOINT INJECTIONS — Injection parameters: up to 2 therapeutic/diagnostic SI injections medically necessary to diagnose pain and achieve therapeutic effect; NOT medically necessary to repeat more frequently than once every 7 days.; SACROILIAC JOINT INJECTIONS — Additional therapeutic SI injections medically necessary if member has improvement in lower back pain numeric rating scale (NRS) of at least 70% of pre-injection NRS score after fluoroscopic or CT controlled injection of local anesthetic with or without steroid into the affected SI joint. If member experiences less than 70% reduction of pain for the expected duration of anesthetic, additional SI joint injections NOT medically necessary.; SACROILIAC JOINT INJECTIONS — Maintenance therapy: once diagnosis established, up to four therapeutic SI injections, repeated no more frequently than once every 7 days, considered medically necessary every 12 months.; INTERLAMINAR EPIDURAL INJECTIONS — Initial interlaminar epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, medically necessary in the outpatient setting for management of members with radiculopathy or sciatica when ALL of: (a) pain is radicular in nature (radicular signs may include positive straight leg raise or dermatomal pattern of sensory loss; in low back pain, radicular means pain and/or numbness radiating below the knee; in neck pain, pain/numbness/weakness in shoulder, arm, wrist, or hand); AND (b) intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out (where indicated for evaluating lumbar, cervical or thoracic pain, advanced diagnostic imaging should be performed within 24 months prior to initiating injections); AND (c) member failed to improve after 4 or more weeks of conservative treatments (e.g., rest, systemic analgesics, physical therapy); AND (d) injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications where appropriate.; INTERLAMINAR EPIDURAL INJECTIONS — Injection parameters: no more than one interlaminar epidural injection medically necessary per session; more than one in a single region per session NOT medically necessary; injection of more than one region per session NOT medically necessary; repeat injections more frequently than every two weeks NOT medically necessary.; INTERLAMINAR EPIDURAL INJECTIONS — Additional injections medically necessary if the initial injection resulted in at least TWO of the following for at least two weeks: (a) 50% or greater relief in pain; AND/OR (b) increase in level of function/physical activity (e.g., return to work); AND/OR (c) reduction in use of pain medication and/or additional medical services such as physical therapy/chiropractic care; AND injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications. Additional epidural injections NOT medically necessary if criteria not met.; INTERLAMINAR EPIDURAL INJECTIONS — Maximum frequency: total of up to 3 interlaminar epidural injections per region, per episode of pain, medically necessary in 6 months; up to four per region (cervical, thoracic, lumbar) per rolling 12-month period medically necessary only upon return of pain and/or deterioration in function and only when responsiveness to prior injections occurred (at least 50% reduction in pain and/or symptoms for two weeks).; NON-PULSED RADIOFREQUENCY FACET DENERVATION — Medically necessary for treatment of members with intractable cervical or back pain with or without sciatica in the outpatient setting when ALL of: (a) member experienced severe pain limiting activities of daily living for at least 6 months; AND (b) member had no prior spinal fusion surgery at the level to be treated; AND (c) neuroradiologic studies negative or fail to confirm disc herniation; AND (d) member has no significant narrowing of vertebral canal or spinal instability requiring surgery; AND (e) member tried and failed six or more weeks of conservative treatments such as bed rest, back supports, physiotherapy, correction of postural abnormality, as well as pharmacotherapies (e.g., anti-inflammatory agents, analgesics, and muscle relaxants); AND (f) member has two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, evidenced by at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic used.; NON-PULSED RADIOFREQUENCY FACET DENERVATION — Procedure parameters: radiofrequency joint denervations/ablations may be performed at the same level(s) bilaterally, but ablation of no more than three levels medically necessary during the same session/procedure; provided greater than 50% pain relief obtained for at least twelve weeks, further facet denervation procedures at intervals of at least six months per level per side at a maximum of twice per rolling calendar year; only 1 treatment procedure per level per side medically necessary in a 6-month period.; SPINAL FIXATION — Pedicle screws medically necessary for posterior spinal fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).; INTERVERTEBRAL BODY FUSION DEVICES — Medically necessary with allograft or autogenous bone graft for members meeting criteria for lumbar spinal fusion as outlined in CPB 0743 and for thoracic fusion.; INTERVERTEBRAL BODY FUSION DEVICES — Synthetic spine cages/spacers for cervical fusion medically necessary for members meeting criteria in CPB 0743 with ANY of: (1) Cervical corpectomy (removal of half or more of vertebral body, not mere removal of osteophytes and minor decompression) for ONE of: tumors involving one or more vertebrae; OR greater than 50% compression fracture of vertebrae; OR retropulsed bone fragments; OR symptomatic central canal stenosis caused by vertebral body pathology (such as fracture, tumor, or congenital/acquired deformity of vertebral body); OR (2) Cervical fusion for pseudarthrosis in persons with prior fusion; OR (3) Adjacent level disease developed in persons with prior cervical fusion involving a plate, in order to avoid dissection for plate removal when a stand-alone cage/spacer is used. Spine cages otherwise NOT medically necessary for cervical fusion.; INTERVERTEBRAL BODY FUSION DEVICES — Expandable cages medically necessary for members meeting criteria for fusion in CPB 0743 and meeting EITHER: (a) at L2-S1; OR (b) members with osseous defects at the fusion site (i.e., voids or gaps in bone due to trauma, surgical resection, or congenital defects).; PERCUTANEOUS POLYMETHYLMETHACRYLATE VERTEBROPLASTY (PPV), KYPHOPLASTY, OR SPINEJACK SYSTEM — Medically necessary for members with persistent, debilitating pain in thoracic or lumbar vertebral bodies resulting from ANY of: multiple myeloma; OR painful and/or aggressive hemangiomas; OR painful vertebral eosinophilic granuloma; OR painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not to be chronic on recent imaging); OR primary malignant neoplasm of bone or bone marrow; OR secondary osteolytic metastasis, excluding sacrum and coccyx but including cervical; AND when ALL of: (a) pain localized to level of pathology being treated; AND (b) other causes of pain such as spinal stenosis or herniated intervertebral disk ruled out by CT or MRI; AND (c) affected vertebra not extensively destroyed and at least 1/3 of original height with intact posterior cortex.; PERCUTANEOUS VERTEBROPLASTY/KYPHOPLASTY/SPINEJACK — Additional criteria specific to painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not chronic on recent imaging): (a) affected vertebra has at least 25% (1/4) height loss/compression but not extensively destroyed and at least 1/3 of original height with intact posterior cortex; AND (b) maximum of 3 vertebral fractures per procedure; AND (c) severe debilitating pain or loss of mobility that cannot be relieved by a minimum of 6 weeks of optimal non-invasive therapy including physical therapy, bracing and/or oral medications; AND (d) documentation for continuum of care for evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and instructed to participate in an osteoporosis prevention/treatment program.; LATERAL INTERBODY FUSION (including Extreme [XLIF], extra and direct lateral [DLIF]) — An acceptable method of performing medically necessary anterior interbody fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).; COCCYGECTOMY — Medically necessary for individuals with coccygodynia who tried and failed to respond to 6 months of conservative management, including: (a) at least 6 weeks of in-person therapy in the past year — either physical therapy for pelvic floor strengthening OR chiropractic manipulation specifically for coccydynia; AND (b) treatment with medications including non-steroidal anti-inflammatory medications unless a contraindication is documented.; VERTEBRAL BODY REPLACEMENT SPACERS — Medically necessary for vertebral body replacement used in spine surgery for persons with collapsed, damaged or unstable vertebral body resected or excised during total and partial vertebrectomy procedures due to tumor or trauma (should not be confused with interspinous distraction devices).; MINIMALLY INVASIVE TRANSFORAMINAL LUMBAR INTERBODY FUSION WITH DIRECT VISUALIZATION — Medically necessary when criteria met in CPB 0743 - Spinal Surgery: Laminectomy and Fusion.; CEMENTOPLASTY — Medically necessary for individuals with bone pain from pelvic bone metastases with reduced mobility and failed conventional pain treatments (e.g., acetaminophen, NSAIDs, and opioids). (For cementoplasty for vertebral indications, see vertebroplasty section.); SACROILIAC JOINT FUSION — Minimally invasive (transfixion) fusion medically necessary for sacroiliac joint syndrome interfering with activities of daily living when ALL of the following are met: (1) Adults 18 years of age or older with SIJ pain for greater than 6 months (or greater than 18 months for pregnancy-induced pelvic girdle pain); AND (2) Diagnosis of SI joint as primary pain generator based on ALL of the sub-criteria; AND (3) Baseline lower back pain score of at least 5 on a 0-10 NRS; AND (4) Member tried 6 months of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and at least three months of formal in-person physical therapy in the past year; AND (5) Radiologic evidence of SI joint degeneration on imaging; AND (6) Member nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 1 year prior to surgery (for recent nicotine use, documentation of nicotine cessation including a lab report — not surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml or urinary cotinine ≤10 ng/ml drawn within 6 weeks prior to surgery).; SACROILIAC JOINT FUSION (minimally invasive) — 'SI joint as primary pain generator' sub-criteria, ALL required: (a) pain at or close to PSIS with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (b) at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (c) other causes of low back pain ruled out (lumbar disc degeneration, disc herniation, spondylolisthesis, spinal stenosis, facet degeneration, vertebral body fracture) with (i) clinician documentation that other neighboring motion segments evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate, AND (ii) recent (within 6 months) diagnostic imaging including ALL of: plain X-rays and/or cross-sectional imaging (CT or MRI) of pelvis excluding destructive lesions (tumor, infection), acute fracture or inflammatory arthropathy not properly addressed by SIJ fusion; plain X-rays of pelvis including ipsilateral hip to exclude concomitant hip pathology; and cross-sectional imaging (CT or MRI) of lumbar spine excluding concomitant neural compression or other degenerative conditions; AND (d) SI pathology NOT caused by autoimmune disease (e.g., ankylosing spondylitis) AND/OR neoplasia AND/OR crystal arthropathy; AND (e) member does NOT have generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND (f) improvement in lower back pain NRS of at least 70% of pre-injection NRS after two separate fluoroscopic or CT controlled injections of local anesthetic (at least one therapeutic injection including steroid) into the affected SI joint within the past year, isolated to only the SI joint (cannot be used if combined with other injections such as hip, trochanteric bursa, or lumbar spine).; SACROILIAC JOINT FUSION — Open SI joint fusion medically necessary for: sacroiliac joint infection; OR tumor involving sacrum; OR sacroiliac pain due to severe traumatic injury where a trial of external fixator was successful in providing pain relief.; INTRAMUSCULAR OR INTRAVENOUS INJECTION OF KETOROLAC TROMETHAMINE (TORADOL) — Medically necessary for short-term (up to 5 days) treatment of adults with acute back pain and/or neck pain.; THE SPINAL SYSTEM-X (CORUS) — A supply and not an implant; covered as part of the global surgical fee and not separately reimbursable.. Applies to 16 codes: 22513, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 62320, 62321, 62322, 62323, 27096, 64635, 62263.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. The bulletin provides no specific list of procedures requiring precertification and no detailed submission instructions, contact information, or process steps beyond directing clinicians to the CPT code search tool. Documentation: For sacroiliac joint fusion (nicotine cessation, recent nicotine users): a lab report — not a surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml (or urinary cotinine ≤10 ng/ml) drawn within 6 weeks prior to surgery.; For vertebroplasty/kyphoplasty in osteoporotic fractures: documentation for continuum of care for an evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and that the member was instructed to participate in an osteoporosis prevention/treatment program.; For sacroiliac joint injections/fusion: clinician documentation that other neighboring motion segments were evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate based on presentation.; For sacroiliac joint fusion: recent (within 6 months) diagnostic imaging studies including plain X-rays and/or cross-sectional imaging (CT or MRI) of the pelvis, plain X-rays of the pelvis including the ipsilateral hip, and cross-sectional imaging (CT or MRI) of the lumbar spine.; For radiofrequency facet denervation: documentation of two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, with at least 80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic used.; For coccygectomy: documentation of a contraindication where NSAID treatment is not used.
Trap
Policy exclusions and limitations: Additional sets of facet injections or medial branch blocks at the same levels and side: experimental, investigational, or unproven (no proven value).; Diagnostic facet joint injections NOT medically necessary where radiofrequency facet neurolysis is NOT being considered.; Diagnostic facet joint injections experimental, investigational, or unproven for neck and back pain with untreated radiculopathy.; Facet joint injections (intra-articular and medial branch blocks) containing corticosteroids are considered therapeutic injections only.; Facet joint injections as therapy for back and neck pain and all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of facet injections: experimental, investigational, or unproven (insufficient evidence).; Additional sets of trigger point injections NOT medically necessary if no clinical response achieved.; Trigger point injections for all other indications: experimental, investigational, or unproven (effectiveness not established for other indications).; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven (insufficient evidence).; Ultrasound guidance of sacroiliac joint injections: NOT medically necessary.; Sacroiliac joint injections for all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of epidural injections: experimental, investigational, or unproven (insufficient evidence).; Interlaminar epidural injections for non-specific low back pain (LBP) and failed back syndrome: experimental, investigational, or unproven (effectiveness not established).; Additional interlaminar epidural injections per region per rolling 12-month period beyond the allowed maximum: NOT medically necessary; experimental, investigational, or unproven (no proven value).; Non-pulsed radiofrequency facet denervation for all other indications: experimental, investigational, or unproven (effectiveness not established).; Interspinous or interlaminar distraction or stabilization devices, with or without lumbar laminectomy and/or fusion: experimental, investigational, or unproven.; CoFix for interlaminar/interspinous stabilization: experimental, investigational, or unproven.; Spine cages otherwise NOT medically necessary for cervical fusion (not proven more effective than bone graft).; Spine cages and structural allograft for indications other than interbody fusion: experimental, investigational, or unproven (effectiveness not established).; Expandable cages for all other indications: experimental, investigational, or unproven.; Vertebroplasty/kyphoplasty/SpineJack for all other indications (other than those listed as medically necessary): experimental, investigational, or unproven.; Sacroiliac joint fusions for all other indications: experimental, investigational, or unproven (effectiveness not established).; Posterior non-transfixing sacroiliac joint fixations, or use of additional joint implants with a transfixing device ('hybrid' fusions): experimental, investigational, or unproven (insufficient evidence and long-term outcomes).; AccuraScope procedure: experimental, investigational, or unproven.; AnchorKnot Tissue Approximation Kit (Anchor Orthopedics) for lumbar discectomy: experimental, investigational, or unproven.; Annulus repair devices (Xclose Tissue Repair System, Barricaid, Disc Annular Repair Technology (DART) System): experimental, investigational, or unproven.; BacFast HD for isolated facet fusion: experimental, investigational, or unproven.; Biomet Aspen fusion system (an interlaminar fixation device): experimental, investigational, or unproven.; Chemical ablation (including but not limited to alcohol, phenol, or sodium morrhuate) of facet joints: experimental, investigational, or unproven.; Chymopapain chemonucleolysis, for all indications, including acute LBP alone, cauda equina syndrome, herniated discs, multiple back operations (failed back surgery syndrome), neurologic disease (e.g., multiple sclerosis), pregnancy, profound or rapidly progressive neurologic deficit, sciatica due to herniated disc, sequestered disc fragment, severe spinal stenosis, severe spondylolisthesis, spinal cord tumor, spinal instability, and when performed with chondroitinase ABC or agents other than chymopapain: experimental, investigational, or unproven.; Coccygeal ganglion (ganglion impar) block for coccydynia, pelvic pain, and all other indications: experimental, investigational, or unproven.; Cooled radiofrequency ablation (e.g., Coolief) for facet denervation: experimental, investigational, or unproven.; Cryoablation (cryoanesthesia, cryodenervation, cryoneurolysis, or cryosurgery) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Custom (patient-specific) synthetic cages/spacers (e.g., Carlsmed Aprevo) for spinal fusion: experimental, investigational, or unproven.; Deuk Laser Disc Repair: experimental, investigational, or unproven.; Devices for annular repair (e.g., Inclose Surgical Mesh System): experimental, investigational, or unproven.; Direct visual rhizotomy (extradural transection or avulsion of other spinal nerve) for chronic low back pain: experimental, investigational, or unproven.; Disc-FX System for treatment (disc decompression, ablation, or annular modulation) of contained disc herniations in cervical, thoracic, and lumbar spine: experimental, investigational, or unproven.; DiscoGel (intradiscal alcohol injection) for treatment of back and neck pain: experimental, investigational, or unproven.; Discseel procedure (regenerative spine procedure) for treatment of back pain: experimental, investigational, or unproven.; Dynamic (intervertebral) stabilization (e.g., BioFlex, CD Horizon Agile Dynamic Stabilization Device, DSS Dynamic Soft Stabilization System, Dynabolt Dynamic Stabilization System, Dynesys Spinal System, Graf ligamentoplasty/Graf artificial ligament, Isobar Spinal System, NFix, Satellite Spinal System, Stabilimax NZ Dynamic Spine Stabilization System, and Zodiak DynaMo System): experimental, investigational, or unproven.; Endoscopic laser foraminoplasty, endoscopic foraminotomy, laminotomy, and rhizotomy (endoscopic radiofrequency ablation): experimental, investigational, or unproven.; Endoscopic transforaminal diskectomy: experimental, investigational, or unproven.; Epidural fat grafting during lumbar decompression laminectomy/discectomy: experimental, investigational, or unproven.; Epidural injections of lytic agents (e.g., hyaluronidase, hypertonic saline) or mechanical lysis in treatment of adhesive arachnoiditis, epidural fibrosis, failed back syndrome, or other indications: experimental, investigational, or unproven.; Epidural steroid injections for treatment of non-radicular low back pain: experimental, investigational, or unproven.; Epiduroscopy (also known as epidural myeloscopy, epidural spinal endoscopy, myeloscopy, and spinal endoscopy) for diagnosis and treatment of intractable LBP or other indications: experimental, investigational, or unproven.; Facet chemodenervation/chemical facet neurolysis: experimental, investigational, or unproven.; Facet joint allograft implants (NuFix facet fusion, TruFuse facet fusion): experimental, investigational, or unproven.; Facet joint implantation (Total Posterior-element System (TOPS) (Premia Spine), Total Facet Arthroplasty System (TFAS) (Archus Orthopedics), ACADIA Facet Replacement System (Facet Solutions/Globus Medical)): experimental, investigational, or unproven.; Far lateral microendoscopic diskectomy (FLMED) for extra-foraminal lumbar disc herniations or other indications: experimental, investigational, or unproven.; Fluoroscopic guidance for trigger point injection: experimental, investigational, or unproven.; Hardware injections/blocks: experimental, investigational, or unproven.; iFuse Bedrock Granite Implant System: experimental, investigational, or unproven.; Injection of steroid into the ilio-lumbar ligament for treatment of low back pain (LBP): experimental, investigational, or unproven.; Interlaminar lumbar instrumented fusion (ILIF): experimental, investigational, or unproven.; Interspinous and interlaminar distraction devices: experimental, investigational, or unproven.; Interspinous fixation devices (Benefix Interspinous Fixation System, CD HORIZON SPIRE Plate, PrimaLOK SP, SP-Fix Spinous Process Fixation Plate, and Stabilink interspinous fixation device) for spinal stenosis or other indications: experimental, investigational, or unproven.; Intracept System (intra-osseous basivertebral nerve ablation) for treatment of low back pain and neck pain: experimental, investigational, or unproven.; Intradiscal injection of local anesthetic for treatment of low back pain: experimental, investigational, or unproven.; Intradiscal injection of notochordal cell-derived matrix for treatment of intervertebral disc disease: experimental, investigational, or unproven.; Intradiscal injection of platelet-rich plasma: experimental, investigational, or unproven.; Intradiscal injection of steroid: experimental, investigational, or unproven.; Intradiscal, paravertebral, or epidural oxygen or ozone injections: experimental, investigational, or unproven.; Intramuscular steroid injection for treatment of back pain and neck pain: experimental, investigational, or unproven.; Intravenous administration of corticosteroids, lidocaine, magnesium, or vitamin B12 (cyanocobalamin) for treatment of back pain and neck pain: experimental, investigational, or unproven.; ION procedure (Ion Facet Screw System): experimental, investigational, or unproven.; Khan kinetic treatment (KKT): experimental, investigational, or unproven.; Laser facet denervation: experimental, investigational, or unproven.; LigaPASS System for use as a ligament augmentation technique in spinal fusions: experimental, investigational, or unproven.; Least invasive lumbar decompression interbody fusion (LINDIF): experimental, investigational, or unproven.; Magnetic resonance imaging-guided focused ultrasound (MRgFUS) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Microendoscopic discectomy (MED; lumbar endoscopic discectomy utilizing microscope) for decompression of lumbar spine stenosis, lumbar disc herniation, or other indications: experimental, investigational, or unproven.; Microsurgical anterior foraminotomy for cervical spondylotic myelopathy or other indications: experimental, investigational, or unproven.; Minimally invasive/endoscopic cervical laminoforaminotomy for cervical radiculopathy/lateral and foraminal cervical disc herniations or other indications: experimental, investigational, or unproven.; Minimally invasive lumbar decompression (MILD) procedure (percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements under indirect image guidance) for lumbar canal stenosis or other indications: experimental, investigational, or unproven.; Minimally invasive thoracic discectomy for treatment of back pain: experimental, investigational, or unproven.; Minimally invasive endoscopic transforaminal lumbar interbody fusion (endoscopic MITLIF; endoscopic MAST fusion) for lumbar disc degeneration and instability or other indications: experimental, investigational, or unproven.; OptiMesh grafting system: experimental, investigational, or unproven.; Percutaneous cement discoplasty for treatment of lumbar degenerative diseases: experimental, investigational, or unproven.; Percutaneous cervical and lumbar diskectomy: experimental, investigational, or unproven.; Percutaneous endoscopic diskectomy with or without laser (PELD) (arthroscopic microdiskectomy or Yeung Endoscopic Spinal Surgery System [Y.E.S.S.]): experimental, investigational, or unproven.; Percutaneous lumbar discectomy (manual or automated) for treatment of degenerative disc disease: experimental, investigational, or unproven.; Piriformis muscle resection and other surgery for piriformis syndrome: experimental, investigational, or unproven.; Platelet-rich plasma for facet joint injections: experimental, investigational, or unproven.; Posterior intrafacet implants (e.g., DTRAX Cervical Cage) for posterior cervical fusion: experimental, investigational, or unproven.; Psoas compartment block for lumbar radiculopathy or myositis ossification: experimental, investigational, or unproven.; Puborectalis and iliococcygeus trigger point injections for treatment of pelvic pain: experimental, investigational, or unproven.; Racz procedure (epidural adhesiolysis with Racz catheter) for treatment of members with adhesive arachnoiditis, epidural adhesions, failed back syndrome from multiple previous surgeries for herniated lumbar disk, or other indications: experimental, investigational, or unproven.; Radiofrequency denervation for sacroiliac joint pain: experimental, investigational, or unproven.; Radiofrequency lesioning of dorsal root ganglia for back pain: experimental, investigational, or unproven.; Radiofrequency lesioning of terminal (peripheral) nerve endings for back pain: experimental, investigational, or unproven.; Radiofrequency/pulsed radiofrequency ablation of trigger point pain: experimental, investigational, or unproven.; Sacroiliac ligament injection for treatment of unspecified dorsalgia: experimental, investigational, or unproven.; Sacroplasty for osteoporotic sacral insufficiency fractures and other indications: experimental, investigational, or unproven.; Tendon and/or tendon sheath injections for the spine: experimental, investigational, or unproven.; Tendon sheath injections for treatment of back pain: experimental, investigational, or unproven.; Therapeutic facet joint injections: experimental, investigational, or unproven.; Total Facet Arthroplasty System (TFAS) for treatment of spinal stenosis: experimental, investigational, or unproven.; Transforaminal percutaneous endoscopic discectomy for treatment of discogenic low back pain: experimental, investigational, or unproven.; Ultrasound guidance of epidural injections: experimental, investigational, or unproven.; Ultrasound guidance of facet injections: experimental, investigational, or unproven.; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven.; Vesselplasty (e.g., Vessel-X): experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0016 — Back Pain - Invasive Procedures

Coverage criteria

  • FACET JOINT INJECTIONS — Initial diagnostic facet injection (intra-articular and medial branch block) for diagnosis of facet pain in persons with severe chronic neck and back pain, medically necessary when ALL of: (a) symptoms suggestive of facet joint syndrome (absence of radiculopathy, pain aggravated by extension/rotation/lateral bending of spine, not typically associated with neurological deficits); AND (b) facet-mediated pain confirmed by provocative testing on physical exam (pain exacerbated by extension and rotation); AND (c) imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion); AND (d) pain limits daily activities; AND (e) pain has lasted more than 3 months; AND (f) pain has persisted despite six or more weeks of conservative treatment (including systemic medications and/or physical therapy); AND (g) radiofrequency facet neurolysis is being considered.
  • FACET JOINT INJECTIONS — Injection parameters: no more than three (3) facet joint levels considered medically necessary during the same session/procedure; may be performed bilaterally during the same session for a total of up to six injections.
  • FACET JOINT INJECTIONS — Second diagnostic facet injection medically necessary to confirm validity of clinical response to the initial facet injection when ALL of: (a) administered at the same level as the initial facet injection; AND (b) the initial facet injection produced a positive response (at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic effect). If the initial injection did not produce a positive response, a second diagnostic injection is NOT medically necessary.
  • TRIGGER POINT INJECTIONS — Medically necessary for treating members with chronic neck or back pain or myofascial pain syndrome when ALL of: (a) conservative treatment (bed rest, exercises, heating/cooling modalities, massage, pharmacotherapies such as NSAIDs, muscle relaxants, non-narcotic analgesics) has been tried and failed; AND (b) symptoms have persisted for more than 3 months; AND (c) trigger points identified by palpation; AND (d) trigger point injections not administered in isolation, but provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medication where appropriate.
  • TRIGGER POINT INJECTIONS — Injection parameters: up to 4 sets of injections medically necessary to diagnose origin of pain and achieve therapeutic effect; additional sets NOT medically necessary if no clinical response achieved; NOT medically necessary to repeat more frequently than every 7 days; once diagnosis established and therapeutic effect achieved, rarely medically necessary to repeat more frequently than once every 2 months; repeated injections extending beyond 12 months may be reviewed for continued medical necessity.
  • SACROILIAC JOINT INJECTIONS — Initial therapeutic/diagnostic SI injections medically necessary to relieve pain associated with lower lumbosacral disturbances when ALL of: (a) member has SI joint (SIJ) pain for greater than 3 months; AND (b) member has pain at or close to the posterior superior iliac spine (PSIS) with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (c) member has at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (d) other causes of low back pain ruled out, including lumbar disc degeneration, lumbar disc herniation, lumbar spondylolisthesis, lumbar spinal stenosis, lumbar facet degeneration, and lumbar vertebral body fracture; AND (e) member tried 6 weeks of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and active therapy (including physical therapy where appropriate); AND (f) injections not used in isolation but provided as part of a comprehensive pain management program including physical therapy, education, psychosocial support, and oral medication where appropriate.
  • SACROILIAC JOINT INJECTIONS — Injection parameters: up to 2 therapeutic/diagnostic SI injections medically necessary to diagnose pain and achieve therapeutic effect; NOT medically necessary to repeat more frequently than once every 7 days.
  • SACROILIAC JOINT INJECTIONS — Additional therapeutic SI injections medically necessary if member has improvement in lower back pain numeric rating scale (NRS) of at least 70% of pre-injection NRS score after fluoroscopic or CT controlled injection of local anesthetic with or without steroid into the affected SI joint. If member experiences less than 70% reduction of pain for the expected duration of anesthetic, additional SI joint injections NOT medically necessary.
  • SACROILIAC JOINT INJECTIONS — Maintenance therapy: once diagnosis established, up to four therapeutic SI injections, repeated no more frequently than once every 7 days, considered medically necessary every 12 months.
  • INTERLAMINAR EPIDURAL INJECTIONS — Initial interlaminar epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, medically necessary in the outpatient setting for management of members with radiculopathy or sciatica when ALL of: (a) pain is radicular in nature (radicular signs may include positive straight leg raise or dermatomal pattern of sensory loss; in low back pain, radicular means pain and/or numbness radiating below the knee; in neck pain, pain/numbness/weakness in shoulder, arm, wrist, or hand); AND (b) intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out (where indicated for evaluating lumbar, cervical or thoracic pain, advanced diagnostic imaging should be performed within 24 months prior to initiating injections); AND (c) member failed to improve after 4 or more weeks of conservative treatments (e.g., rest, systemic analgesics, physical therapy); AND (d) injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications where appropriate.
  • INTERLAMINAR EPIDURAL INJECTIONS — Injection parameters: no more than one interlaminar epidural injection medically necessary per session; more than one in a single region per session NOT medically necessary; injection of more than one region per session NOT medically necessary; repeat injections more frequently than every two weeks NOT medically necessary.
  • INTERLAMINAR EPIDURAL INJECTIONS — Additional injections medically necessary if the initial injection resulted in at least TWO of the following for at least two weeks: (a) 50% or greater relief in pain; AND/OR (b) increase in level of function/physical activity (e.g., return to work); AND/OR (c) reduction in use of pain medication and/or additional medical services such as physical therapy/chiropractic care; AND injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications. Additional epidural injections NOT medically necessary if criteria not met.
  • INTERLAMINAR EPIDURAL INJECTIONS — Maximum frequency: total of up to 3 interlaminar epidural injections per region, per episode of pain, medically necessary in 6 months; up to four per region (cervical, thoracic, lumbar) per rolling 12-month period medically necessary only upon return of pain and/or deterioration in function and only when responsiveness to prior injections occurred (at least 50% reduction in pain and/or symptoms for two weeks).
  • NON-PULSED RADIOFREQUENCY FACET DENERVATION — Medically necessary for treatment of members with intractable cervical or back pain with or without sciatica in the outpatient setting when ALL of: (a) member experienced severe pain limiting activities of daily living for at least 6 months; AND (b) member had no prior spinal fusion surgery at the level to be treated; AND (c) neuroradiologic studies negative or fail to confirm disc herniation; AND (d) member has no significant narrowing of vertebral canal or spinal instability requiring surgery; AND (e) member tried and failed six or more weeks of conservative treatments such as bed rest, back supports, physiotherapy, correction of postural abnormality, as well as pharmacotherapies (e.g., anti-inflammatory agents, analgesics, and muscle relaxants); AND (f) member has two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, evidenced by at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic used.
  • NON-PULSED RADIOFREQUENCY FACET DENERVATION — Procedure parameters: radiofrequency joint denervations/ablations may be performed at the same level(s) bilaterally, but ablation of no more than three levels medically necessary during the same session/procedure; provided greater than 50% pain relief obtained for at least twelve weeks, further facet denervation procedures at intervals of at least six months per level per side at a maximum of twice per rolling calendar year; only 1 treatment procedure per level per side medically necessary in a 6-month period.
  • SPINAL FIXATION — Pedicle screws medically necessary for posterior spinal fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).
  • INTERVERTEBRAL BODY FUSION DEVICES — Medically necessary with allograft or autogenous bone graft for members meeting criteria for lumbar spinal fusion as outlined in CPB 0743 and for thoracic fusion.
  • INTERVERTEBRAL BODY FUSION DEVICES — Synthetic spine cages/spacers for cervical fusion medically necessary for members meeting criteria in CPB 0743 with ANY of: (1) Cervical corpectomy (removal of half or more of vertebral body, not mere removal of osteophytes and minor decompression) for ONE of: tumors involving one or more vertebrae; OR greater than 50% compression fracture of vertebrae; OR retropulsed bone fragments; OR symptomatic central canal stenosis caused by vertebral body pathology (such as fracture, tumor, or congenital/acquired deformity of vertebral body); OR (2) Cervical fusion for pseudarthrosis in persons with prior fusion; OR (3) Adjacent level disease developed in persons with prior cervical fusion involving a plate, in order to avoid dissection for plate removal when a stand-alone cage/spacer is used. Spine cages otherwise NOT medically necessary for cervical fusion.
  • INTERVERTEBRAL BODY FUSION DEVICES — Expandable cages medically necessary for members meeting criteria for fusion in CPB 0743 and meeting EITHER: (a) at L2-S1; OR (b) members with osseous defects at the fusion site (i.e., voids or gaps in bone due to trauma, surgical resection, or congenital defects).
  • PERCUTANEOUS POLYMETHYLMETHACRYLATE VERTEBROPLASTY (PPV), KYPHOPLASTY, OR SPINEJACK SYSTEM — Medically necessary for members with persistent, debilitating pain in thoracic or lumbar vertebral bodies resulting from ANY of: multiple myeloma; OR painful and/or aggressive hemangiomas; OR painful vertebral eosinophilic granuloma; OR painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not to be chronic on recent imaging); OR primary malignant neoplasm of bone or bone marrow; OR secondary osteolytic metastasis, excluding sacrum and coccyx but including cervical; AND when ALL of: (a) pain localized to level of pathology being treated; AND (b) other causes of pain such as spinal stenosis or herniated intervertebral disk ruled out by CT or MRI; AND (c) affected vertebra not extensively destroyed and at least 1/3 of original height with intact posterior cortex.
  • PERCUTANEOUS VERTEBROPLASTY/KYPHOPLASTY/SPINEJACK — Additional criteria specific to painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not chronic on recent imaging): (a) affected vertebra has at least 25% (1/4) height loss/compression but not extensively destroyed and at least 1/3 of original height with intact posterior cortex; AND (b) maximum of 3 vertebral fractures per procedure; AND (c) severe debilitating pain or loss of mobility that cannot be relieved by a minimum of 6 weeks of optimal non-invasive therapy including physical therapy, bracing and/or oral medications; AND (d) documentation for continuum of care for evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and instructed to participate in an osteoporosis prevention/treatment program.
  • LATERAL INTERBODY FUSION (including Extreme [XLIF], extra and direct lateral [DLIF]) — An acceptable method of performing medically necessary anterior interbody fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).
  • COCCYGECTOMY — Medically necessary for individuals with coccygodynia who tried and failed to respond to 6 months of conservative management, including: (a) at least 6 weeks of in-person therapy in the past year — either physical therapy for pelvic floor strengthening OR chiropractic manipulation specifically for coccydynia; AND (b) treatment with medications including non-steroidal anti-inflammatory medications unless a contraindication is documented.
  • VERTEBRAL BODY REPLACEMENT SPACERS — Medically necessary for vertebral body replacement used in spine surgery for persons with collapsed, damaged or unstable vertebral body resected or excised during total and partial vertebrectomy procedures due to tumor or trauma (should not be confused with interspinous distraction devices).
  • MINIMALLY INVASIVE TRANSFORAMINAL LUMBAR INTERBODY FUSION WITH DIRECT VISUALIZATION — Medically necessary when criteria met in CPB 0743 - Spinal Surgery: Laminectomy and Fusion.
  • CEMENTOPLASTY — Medically necessary for individuals with bone pain from pelvic bone metastases with reduced mobility and failed conventional pain treatments (e.g., acetaminophen, NSAIDs, and opioids). (For cementoplasty for vertebral indications, see vertebroplasty section.)
  • SACROILIAC JOINT FUSION — Minimally invasive (transfixion) fusion medically necessary for sacroiliac joint syndrome interfering with activities of daily living when ALL of the following are met: (1) Adults 18 years of age or older with SIJ pain for greater than 6 months (or greater than 18 months for pregnancy-induced pelvic girdle pain); AND (2) Diagnosis of SI joint as primary pain generator based on ALL of the sub-criteria; AND (3) Baseline lower back pain score of at least 5 on a 0-10 NRS; AND (4) Member tried 6 months of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and at least three months of formal in-person physical therapy in the past year; AND (5) Radiologic evidence of SI joint degeneration on imaging; AND (6) Member nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 1 year prior to surgery (for recent nicotine use, documentation of nicotine cessation including a lab report — not surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml or urinary cotinine ≤10 ng/ml drawn within 6 weeks prior to surgery).
  • SACROILIAC JOINT FUSION (minimally invasive) — 'SI joint as primary pain generator' sub-criteria, ALL required: (a) pain at or close to PSIS with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (b) at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (c) other causes of low back pain ruled out (lumbar disc degeneration, disc herniation, spondylolisthesis, spinal stenosis, facet degeneration, vertebral body fracture) with (i) clinician documentation that other neighboring motion segments evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate, AND (ii) recent (within 6 months) diagnostic imaging including ALL of: plain X-rays and/or cross-sectional imaging (CT or MRI) of pelvis excluding destructive lesions (tumor, infection), acute fracture or inflammatory arthropathy not properly addressed by SIJ fusion; plain X-rays of pelvis including ipsilateral hip to exclude concomitant hip pathology; and cross-sectional imaging (CT or MRI) of lumbar spine excluding concomitant neural compression or other degenerative conditions; AND (d) SI pathology NOT caused by autoimmune disease (e.g., ankylosing spondylitis) AND/OR neoplasia AND/OR crystal arthropathy; AND (e) member does NOT have generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND (f) improvement in lower back pain NRS of at least 70% of pre-injection NRS after two separate fluoroscopic or CT controlled injections of local anesthetic (at least one therapeutic injection including steroid) into the affected SI joint within the past year, isolated to only the SI joint (cannot be used if combined with other injections such as hip, trochanteric bursa, or lumbar spine).
  • SACROILIAC JOINT FUSION — Open SI joint fusion medically necessary for: sacroiliac joint infection; OR tumor involving sacrum; OR sacroiliac pain due to severe traumatic injury where a trial of external fixator was successful in providing pain relief.
  • INTRAMUSCULAR OR INTRAVENOUS INJECTION OF KETOROLAC TROMETHAMINE (TORADOL) — Medically necessary for short-term (up to 5 days) treatment of adults with acute back pain and/or neck pain.
  • THE SPINAL SYSTEM-X (CORUS) — A supply and not an implant; covered as part of the global surgical fee and not separately reimbursable.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • For sacroiliac joint fusion (nicotine cessation, recent nicotine users): a lab report — not a surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml (or urinary cotinine ≤10 ng/ml) drawn within 6 weeks prior to surgery.
  • For vertebroplasty/kyphoplasty in osteoporotic fractures: documentation for continuum of care for an evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and that the member was instructed to participate in an osteoporosis prevention/treatment program.
  • For sacroiliac joint injections/fusion: clinician documentation that other neighboring motion segments were evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate based on presentation.
  • For sacroiliac joint fusion: recent (within 6 months) diagnostic imaging studies including plain X-rays and/or cross-sectional imaging (CT or MRI) of the pelvis, plain X-rays of the pelvis including the ipsilateral hip, and cross-sectional imaging (CT or MRI) of the lumbar spine.
  • For radiofrequency facet denervation: documentation of two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, with at least 80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic used.
  • For coccygectomy: documentation of a contraindication where NSAID treatment is not used.

Frequently asked questions

When does Aetna cover Back Pain - Invasive Procedures (CPT 22513), and what gets it denied?
Aetna CPB 0016 covers invasive procedures for back and neck pain — including diagnostic facet, trigger point, sacroiliac, and interlaminar epidural injections, non-pulsed radiofrequency facet denervation, various spinal fusion/fixation hardware and interbody devices, vertebroplasty/kyphoplasty, coccygectomy, and minimally invasive SI joint fusion — only when strict, procedure-specific gates are met: documented diagnosis, prior failure of weeks-to-months of conservative therapy, supporting imaging, and (for injections) a demonstrated prior response such as at least 70-80% pain relief. A large number of newer or alternative techniques and devices (e.g., dynamic stabilization, endoscopic/percutaneous discectomy, basivertebral nerve ablation, SI joint radiofrequency denervation, annular repair, ultrasound/EMG injection guidance) are deemed experimental, investigational, or unproven and are not covered. Coverage criteria include: FACET JOINT INJECTIONS — Initial diagnostic facet injection (intra-articular and medial branch block) for diagnosis of facet pain in persons with severe chronic neck and back pain, medically necessary when ALL of: (a) symptoms suggestive of facet joint syndrome (absence of radiculopathy, pain aggravated by extension/rotation/lateral bending of spine, not typically associated with neurological deficits); AND (b) facet-mediated pain confirmed by provocative testing on physical exam (pain exacerbated by extension and rotation); AND (c) imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion); AND (d) pain limits daily activities; AND (e) pain has lasted more than 3 months; AND (f) pain has persisted despite six or more weeks of conservative treatment (including systemic medications and/or physical therapy); AND (g) radiofrequency facet neurolysis is being considered.; FACET JOINT INJECTIONS — Injection parameters: no more than three (3) facet joint levels considered medically necessary during the same session/procedure; may be performed bilaterally during the same session for a total of up to six injections.; FACET JOINT INJECTIONS — Second diagnostic facet injection medically necessary to confirm validity of clinical response to the initial facet injection when ALL of: (a) administered at the same level as the initial facet injection; AND (b) the initial facet injection produced a positive response (at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic effect). If the initial injection did not produce a positive response, a second diagnostic injection is NOT medically necessary.; TRIGGER POINT INJECTIONS — Medically necessary for treating members with chronic neck or back pain or myofascial pain syndrome when ALL of: (a) conservative treatment (bed rest, exercises, heating/cooling modalities, massage, pharmacotherapies such as NSAIDs, muscle relaxants, non-narcotic analgesics) has been tried and failed; AND (b) symptoms have persisted for more than 3 months; AND (c) trigger points identified by palpation; AND (d) trigger point injections not administered in isolation, but provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medication where appropriate.; TRIGGER POINT INJECTIONS — Injection parameters: up to 4 sets of injections medically necessary to diagnose origin of pain and achieve therapeutic effect; additional sets NOT medically necessary if no clinical response achieved; NOT medically necessary to repeat more frequently than every 7 days; once diagnosis established and therapeutic effect achieved, rarely medically necessary to repeat more frequently than once every 2 months; repeated injections extending beyond 12 months may be reviewed for continued medical necessity.; SACROILIAC JOINT INJECTIONS — Initial therapeutic/diagnostic SI injections medically necessary to relieve pain associated with lower lumbosacral disturbances when ALL of: (a) member has SI joint (SIJ) pain for greater than 3 months; AND (b) member has pain at or close to the posterior superior iliac spine (PSIS) with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (c) member has at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (d) other causes of low back pain ruled out, including lumbar disc degeneration, lumbar disc herniation, lumbar spondylolisthesis, lumbar spinal stenosis, lumbar facet degeneration, and lumbar vertebral body fracture; AND (e) member tried 6 weeks of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and active therapy (including physical therapy where appropriate); AND (f) injections not used in isolation but provided as part of a comprehensive pain management program including physical therapy, education, psychosocial support, and oral medication where appropriate.; SACROILIAC JOINT INJECTIONS — Injection parameters: up to 2 therapeutic/diagnostic SI injections medically necessary to diagnose pain and achieve therapeutic effect; NOT medically necessary to repeat more frequently than once every 7 days.; SACROILIAC JOINT INJECTIONS — Additional therapeutic SI injections medically necessary if member has improvement in lower back pain numeric rating scale (NRS) of at least 70% of pre-injection NRS score after fluoroscopic or CT controlled injection of local anesthetic with or without steroid into the affected SI joint. If member experiences less than 70% reduction of pain for the expected duration of anesthetic, additional SI joint injections NOT medically necessary.; SACROILIAC JOINT INJECTIONS — Maintenance therapy: once diagnosis established, up to four therapeutic SI injections, repeated no more frequently than once every 7 days, considered medically necessary every 12 months.; INTERLAMINAR EPIDURAL INJECTIONS — Initial interlaminar epidural injections of corticosteroid preparations (e.g., Depo-Medrol), with or without added anesthetic agents, medically necessary in the outpatient setting for management of members with radiculopathy or sciatica when ALL of: (a) pain is radicular in nature (radicular signs may include positive straight leg raise or dermatomal pattern of sensory loss; in low back pain, radicular means pain and/or numbness radiating below the knee; in neck pain, pain/numbness/weakness in shoulder, arm, wrist, or hand); AND (b) intraspinal tumor or other space-occupying lesion, or non-spinal origin for pain, has been ruled out (where indicated for evaluating lumbar, cervical or thoracic pain, advanced diagnostic imaging should be performed within 24 months prior to initiating injections); AND (c) member failed to improve after 4 or more weeks of conservative treatments (e.g., rest, systemic analgesics, physical therapy); AND (d) injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications where appropriate.; INTERLAMINAR EPIDURAL INJECTIONS — Injection parameters: no more than one interlaminar epidural injection medically necessary per session; more than one in a single region per session NOT medically necessary; injection of more than one region per session NOT medically necessary; repeat injections more frequently than every two weeks NOT medically necessary.; INTERLAMINAR EPIDURAL INJECTIONS — Additional injections medically necessary if the initial injection resulted in at least TWO of the following for at least two weeks: (a) 50% or greater relief in pain; AND/OR (b) increase in level of function/physical activity (e.g., return to work); AND/OR (c) reduction in use of pain medication and/or additional medical services such as physical therapy/chiropractic care; AND injections provided as part of a comprehensive pain management program including physical therapy, patient education, psychosocial support, and oral medications. Additional epidural injections NOT medically necessary if criteria not met.; INTERLAMINAR EPIDURAL INJECTIONS — Maximum frequency: total of up to 3 interlaminar epidural injections per region, per episode of pain, medically necessary in 6 months; up to four per region (cervical, thoracic, lumbar) per rolling 12-month period medically necessary only upon return of pain and/or deterioration in function and only when responsiveness to prior injections occurred (at least 50% reduction in pain and/or symptoms for two weeks).; NON-PULSED RADIOFREQUENCY FACET DENERVATION — Medically necessary for treatment of members with intractable cervical or back pain with or without sciatica in the outpatient setting when ALL of: (a) member experienced severe pain limiting activities of daily living for at least 6 months; AND (b) member had no prior spinal fusion surgery at the level to be treated; AND (c) neuroradiologic studies negative or fail to confirm disc herniation; AND (d) member has no significant narrowing of vertebral canal or spinal instability requiring surgery; AND (e) member tried and failed six or more weeks of conservative treatments such as bed rest, back supports, physiotherapy, correction of postural abnormality, as well as pharmacotherapies (e.g., anti-inflammatory agents, analgesics, and muscle relaxants); AND (f) member has two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, evidenced by at least 80% relief of facet-mediated pain for at least the expected minimum duration of local anesthetic used.; NON-PULSED RADIOFREQUENCY FACET DENERVATION — Procedure parameters: radiofrequency joint denervations/ablations may be performed at the same level(s) bilaterally, but ablation of no more than three levels medically necessary during the same session/procedure; provided greater than 50% pain relief obtained for at least twelve weeks, further facet denervation procedures at intervals of at least six months per level per side at a maximum of twice per rolling calendar year; only 1 treatment procedure per level per side medically necessary in a 6-month period.; SPINAL FIXATION — Pedicle screws medically necessary for posterior spinal fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).; INTERVERTEBRAL BODY FUSION DEVICES — Medically necessary with allograft or autogenous bone graft for members meeting criteria for lumbar spinal fusion as outlined in CPB 0743 and for thoracic fusion.; INTERVERTEBRAL BODY FUSION DEVICES — Synthetic spine cages/spacers for cervical fusion medically necessary for members meeting criteria in CPB 0743 with ANY of: (1) Cervical corpectomy (removal of half or more of vertebral body, not mere removal of osteophytes and minor decompression) for ONE of: tumors involving one or more vertebrae; OR greater than 50% compression fracture of vertebrae; OR retropulsed bone fragments; OR symptomatic central canal stenosis caused by vertebral body pathology (such as fracture, tumor, or congenital/acquired deformity of vertebral body); OR (2) Cervical fusion for pseudarthrosis in persons with prior fusion; OR (3) Adjacent level disease developed in persons with prior cervical fusion involving a plate, in order to avoid dissection for plate removal when a stand-alone cage/spacer is used. Spine cages otherwise NOT medically necessary for cervical fusion.; INTERVERTEBRAL BODY FUSION DEVICES — Expandable cages medically necessary for members meeting criteria for fusion in CPB 0743 and meeting EITHER: (a) at L2-S1; OR (b) members with osseous defects at the fusion site (i.e., voids or gaps in bone due to trauma, surgical resection, or congenital defects).; PERCUTANEOUS POLYMETHYLMETHACRYLATE VERTEBROPLASTY (PPV), KYPHOPLASTY, OR SPINEJACK SYSTEM — Medically necessary for members with persistent, debilitating pain in thoracic or lumbar vertebral bodies resulting from ANY of: multiple myeloma; OR painful and/or aggressive hemangiomas; OR painful vertebral eosinophilic granuloma; OR painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not to be chronic on recent imaging); OR primary malignant neoplasm of bone or bone marrow; OR secondary osteolytic metastasis, excluding sacrum and coccyx but including cervical; AND when ALL of: (a) pain localized to level of pathology being treated; AND (b) other causes of pain such as spinal stenosis or herniated intervertebral disk ruled out by CT or MRI; AND (c) affected vertebra not extensively destroyed and at least 1/3 of original height with intact posterior cortex.; PERCUTANEOUS VERTEBROPLASTY/KYPHOPLASTY/SPINEJACK — Additional criteria specific to painful, debilitating osteoporotic acute or subacute collapse/compression fractures (proven not chronic on recent imaging): (a) affected vertebra has at least 25% (1/4) height loss/compression but not extensively destroyed and at least 1/3 of original height with intact posterior cortex; AND (b) maximum of 3 vertebral fractures per procedure; AND (c) severe debilitating pain or loss of mobility that cannot be relieved by a minimum of 6 weeks of optimal non-invasive therapy including physical therapy, bracing and/or oral medications; AND (d) documentation for continuum of care for evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and instructed to participate in an osteoporosis prevention/treatment program.; LATERAL INTERBODY FUSION (including Extreme [XLIF], extra and direct lateral [DLIF]) — An acceptable method of performing medically necessary anterior interbody fusion (see CPB 0743 - Spinal Surgery: Laminectomy and Fusion).; COCCYGECTOMY — Medically necessary for individuals with coccygodynia who tried and failed to respond to 6 months of conservative management, including: (a) at least 6 weeks of in-person therapy in the past year — either physical therapy for pelvic floor strengthening OR chiropractic manipulation specifically for coccydynia; AND (b) treatment with medications including non-steroidal anti-inflammatory medications unless a contraindication is documented.; VERTEBRAL BODY REPLACEMENT SPACERS — Medically necessary for vertebral body replacement used in spine surgery for persons with collapsed, damaged or unstable vertebral body resected or excised during total and partial vertebrectomy procedures due to tumor or trauma (should not be confused with interspinous distraction devices).; MINIMALLY INVASIVE TRANSFORAMINAL LUMBAR INTERBODY FUSION WITH DIRECT VISUALIZATION — Medically necessary when criteria met in CPB 0743 - Spinal Surgery: Laminectomy and Fusion.; CEMENTOPLASTY — Medically necessary for individuals with bone pain from pelvic bone metastases with reduced mobility and failed conventional pain treatments (e.g., acetaminophen, NSAIDs, and opioids). (For cementoplasty for vertebral indications, see vertebroplasty section.); SACROILIAC JOINT FUSION — Minimally invasive (transfixion) fusion medically necessary for sacroiliac joint syndrome interfering with activities of daily living when ALL of the following are met: (1) Adults 18 years of age or older with SIJ pain for greater than 6 months (or greater than 18 months for pregnancy-induced pelvic girdle pain); AND (2) Diagnosis of SI joint as primary pain generator based on ALL of the sub-criteria; AND (3) Baseline lower back pain score of at least 5 on a 0-10 NRS; AND (4) Member tried 6 months of adequate conservative treatment with little or no response, including pharmacotherapy (e.g., NSAIDs), activity modification, and at least three months of formal in-person physical therapy in the past year; AND (5) Radiologic evidence of SI joint degeneration on imaging; AND (6) Member nicotine-free (including smoking, tobacco products, and nicotine replacement therapy) for at least 1 year prior to surgery (for recent nicotine use, documentation of nicotine cessation including a lab report — not surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml or urinary cotinine ≤10 ng/ml drawn within 6 weeks prior to surgery).; SACROILIAC JOINT FUSION (minimally invasive) — 'SI joint as primary pain generator' sub-criteria, ALL required: (a) pain at or close to PSIS with possible radiation into buttocks, posterior thigh, or groin and can point to location of pain (Fortin Finger Test); AND (b) at least 3 of 5 physical exam maneuvers specific for SI joint pain (Compression; Posterior Pelvic Pain Provocation test - P4 / Thigh Thrust; Patrick's test / Fabere; Sacroiliac distraction test; Gaenslen's test); AND (c) other causes of low back pain ruled out (lumbar disc degeneration, disc herniation, spondylolisthesis, spinal stenosis, facet degeneration, vertebral body fracture) with (i) clinician documentation that other neighboring motion segments evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate, AND (ii) recent (within 6 months) diagnostic imaging including ALL of: plain X-rays and/or cross-sectional imaging (CT or MRI) of pelvis excluding destructive lesions (tumor, infection), acute fracture or inflammatory arthropathy not properly addressed by SIJ fusion; plain X-rays of pelvis including ipsilateral hip to exclude concomitant hip pathology; and cross-sectional imaging (CT or MRI) of lumbar spine excluding concomitant neural compression or other degenerative conditions; AND (d) SI pathology NOT caused by autoimmune disease (e.g., ankylosing spondylitis) AND/OR neoplasia AND/OR crystal arthropathy; AND (e) member does NOT have generalized pain behavior (e.g., somatoform disorder) or generalized pain disorders (e.g., fibromyalgia); AND (f) improvement in lower back pain NRS of at least 70% of pre-injection NRS after two separate fluoroscopic or CT controlled injections of local anesthetic (at least one therapeutic injection including steroid) into the affected SI joint within the past year, isolated to only the SI joint (cannot be used if combined with other injections such as hip, trochanteric bursa, or lumbar spine).; SACROILIAC JOINT FUSION — Open SI joint fusion medically necessary for: sacroiliac joint infection; OR tumor involving sacrum; OR sacroiliac pain due to severe traumatic injury where a trial of external fixator was successful in providing pain relief.; INTRAMUSCULAR OR INTRAVENOUS INJECTION OF KETOROLAC TROMETHAMINE (TORADOL) — Medically necessary for short-term (up to 5 days) treatment of adults with acute back pain and/or neck pain.; THE SPINAL SYSTEM-X (CORUS) — A supply and not an implant; covered as part of the global surgical fee and not separately reimbursable.. Applies to 16 codes: 22513, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 62320, 62321, 62322, 62323, 27096, 64635, 62263. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. The bulletin provides no specific list of procedures requiring precertification and no detailed submission instructions, contact information, or process steps beyond directing clinicians to the CPT code search tool. Documentation: For sacroiliac joint fusion (nicotine cessation, recent nicotine users): a lab report — not a surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml (or urinary cotinine ≤10 ng/ml) drawn within 6 weeks prior to surgery.; For vertebroplasty/kyphoplasty in osteoporotic fractures: documentation for continuum of care for an evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and that the member was instructed to participate in an osteoporosis prevention/treatment program.; For sacroiliac joint injections/fusion: clinician documentation that other neighboring motion segments were evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate based on presentation.; For sacroiliac joint fusion: recent (within 6 months) diagnostic imaging studies including plain X-rays and/or cross-sectional imaging (CT or MRI) of the pelvis, plain X-rays of the pelvis including the ipsilateral hip, and cross-sectional imaging (CT or MRI) of the lumbar spine.; For radiofrequency facet denervation: documentation of two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, with at least 80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic used.; For coccygectomy: documentation of a contraindication where NSAID treatment is not used. Policy exclusions and limitations: Additional sets of facet injections or medial branch blocks at the same levels and side: experimental, investigational, or unproven (no proven value).; Diagnostic facet joint injections NOT medically necessary where radiofrequency facet neurolysis is NOT being considered.; Diagnostic facet joint injections experimental, investigational, or unproven for neck and back pain with untreated radiculopathy.; Facet joint injections (intra-articular and medial branch blocks) containing corticosteroids are considered therapeutic injections only.; Facet joint injections as therapy for back and neck pain and all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of facet injections: experimental, investigational, or unproven (insufficient evidence).; Additional sets of trigger point injections NOT medically necessary if no clinical response achieved.; Trigger point injections for all other indications: experimental, investigational, or unproven (effectiveness not established for other indications).; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven (insufficient evidence).; Ultrasound guidance of sacroiliac joint injections: NOT medically necessary.; Sacroiliac joint injections for all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of epidural injections: experimental, investigational, or unproven (insufficient evidence).; Interlaminar epidural injections for non-specific low back pain (LBP) and failed back syndrome: experimental, investigational, or unproven (effectiveness not established).; Additional interlaminar epidural injections per region per rolling 12-month period beyond the allowed maximum: NOT medically necessary; experimental, investigational, or unproven (no proven value).; Non-pulsed radiofrequency facet denervation for all other indications: experimental, investigational, or unproven (effectiveness not established).; Interspinous or interlaminar distraction or stabilization devices, with or without lumbar laminectomy and/or fusion: experimental, investigational, or unproven.; CoFix for interlaminar/interspinous stabilization: experimental, investigational, or unproven.; Spine cages otherwise NOT medically necessary for cervical fusion (not proven more effective than bone graft).; Spine cages and structural allograft for indications other than interbody fusion: experimental, investigational, or unproven (effectiveness not established).; Expandable cages for all other indications: experimental, investigational, or unproven.; Vertebroplasty/kyphoplasty/SpineJack for all other indications (other than those listed as medically necessary): experimental, investigational, or unproven.; Sacroiliac joint fusions for all other indications: experimental, investigational, or unproven (effectiveness not established).; Posterior non-transfixing sacroiliac joint fixations, or use of additional joint implants with a transfixing device ('hybrid' fusions): experimental, investigational, or unproven (insufficient evidence and long-term outcomes).; AccuraScope procedure: experimental, investigational, or unproven.; AnchorKnot Tissue Approximation Kit (Anchor Orthopedics) for lumbar discectomy: experimental, investigational, or unproven.; Annulus repair devices (Xclose Tissue Repair System, Barricaid, Disc Annular Repair Technology (DART) System): experimental, investigational, or unproven.; BacFast HD for isolated facet fusion: experimental, investigational, or unproven.; Biomet Aspen fusion system (an interlaminar fixation device): experimental, investigational, or unproven.; Chemical ablation (including but not limited to alcohol, phenol, or sodium morrhuate) of facet joints: experimental, investigational, or unproven.; Chymopapain chemonucleolysis, for all indications, including acute LBP alone, cauda equina syndrome, herniated discs, multiple back operations (failed back surgery syndrome), neurologic disease (e.g., multiple sclerosis), pregnancy, profound or rapidly progressive neurologic deficit, sciatica due to herniated disc, sequestered disc fragment, severe spinal stenosis, severe spondylolisthesis, spinal cord tumor, spinal instability, and when performed with chondroitinase ABC or agents other than chymopapain: experimental, investigational, or unproven.; Coccygeal ganglion (ganglion impar) block for coccydynia, pelvic pain, and all other indications: experimental, investigational, or unproven.; Cooled radiofrequency ablation (e.g., Coolief) for facet denervation: experimental, investigational, or unproven.; Cryoablation (cryoanesthesia, cryodenervation, cryoneurolysis, or cryosurgery) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Custom (patient-specific) synthetic cages/spacers (e.g., Carlsmed Aprevo) for spinal fusion: experimental, investigational, or unproven.; Deuk Laser Disc Repair: experimental, investigational, or unproven.; Devices for annular repair (e.g., Inclose Surgical Mesh System): experimental, investigational, or unproven.; Direct visual rhizotomy (extradural transection or avulsion of other spinal nerve) for chronic low back pain: experimental, investigational, or unproven.; Disc-FX System for treatment (disc decompression, ablation, or annular modulation) of contained disc herniations in cervical, thoracic, and lumbar spine: experimental, investigational, or unproven.; DiscoGel (intradiscal alcohol injection) for treatment of back and neck pain: experimental, investigational, or unproven.; Discseel procedure (regenerative spine procedure) for treatment of back pain: experimental, investigational, or unproven.; Dynamic (intervertebral) stabilization (e.g., BioFlex, CD Horizon Agile Dynamic Stabilization Device, DSS Dynamic Soft Stabilization System, Dynabolt Dynamic Stabilization System, Dynesys Spinal System, Graf ligamentoplasty/Graf artificial ligament, Isobar Spinal System, NFix, Satellite Spinal System, Stabilimax NZ Dynamic Spine Stabilization System, and Zodiak DynaMo System): experimental, investigational, or unproven.; Endoscopic laser foraminoplasty, endoscopic foraminotomy, laminotomy, and rhizotomy (endoscopic radiofrequency ablation): experimental, investigational, or unproven.; Endoscopic transforaminal diskectomy: experimental, investigational, or unproven.; Epidural fat grafting during lumbar decompression laminectomy/discectomy: experimental, investigational, or unproven.; Epidural injections of lytic agents (e.g., hyaluronidase, hypertonic saline) or mechanical lysis in treatment of adhesive arachnoiditis, epidural fibrosis, failed back syndrome, or other indications: experimental, investigational, or unproven.; Epidural steroid injections for treatment of non-radicular low back pain: experimental, investigational, or unproven.; Epiduroscopy (also known as epidural myeloscopy, epidural spinal endoscopy, myeloscopy, and spinal endoscopy) for diagnosis and treatment of intractable LBP or other indications: experimental, investigational, or unproven.; Facet chemodenervation/chemical facet neurolysis: experimental, investigational, or unproven.; Facet joint allograft implants (NuFix facet fusion, TruFuse facet fusion): experimental, investigational, or unproven.; Facet joint implantation (Total Posterior-element System (TOPS) (Premia Spine), Total Facet Arthroplasty System (TFAS) (Archus Orthopedics), ACADIA Facet Replacement System (Facet Solutions/Globus Medical)): experimental, investigational, or unproven.; Far lateral microendoscopic diskectomy (FLMED) for extra-foraminal lumbar disc herniations or other indications: experimental, investigational, or unproven.; Fluoroscopic guidance for trigger point injection: experimental, investigational, or unproven.; Hardware injections/blocks: experimental, investigational, or unproven.; iFuse Bedrock Granite Implant System: experimental, investigational, or unproven.; Injection of steroid into the ilio-lumbar ligament for treatment of low back pain (LBP): experimental, investigational, or unproven.; Interlaminar lumbar instrumented fusion (ILIF): experimental, investigational, or unproven.; Interspinous and interlaminar distraction devices: experimental, investigational, or unproven.; Interspinous fixation devices (Benefix Interspinous Fixation System, CD HORIZON SPIRE Plate, PrimaLOK SP, SP-Fix Spinous Process Fixation Plate, and Stabilink interspinous fixation device) for spinal stenosis or other indications: experimental, investigational, or unproven.; Intracept System (intra-osseous basivertebral nerve ablation) for treatment of low back pain and neck pain: experimental, investigational, or unproven.; Intradiscal injection of local anesthetic for treatment of low back pain: experimental, investigational, or unproven.; Intradiscal injection of notochordal cell-derived matrix for treatment of intervertebral disc disease: experimental, investigational, or unproven.; Intradiscal injection of platelet-rich plasma: experimental, investigational, or unproven.; Intradiscal injection of steroid: experimental, investigational, or unproven.; Intradiscal, paravertebral, or epidural oxygen or ozone injections: experimental, investigational, or unproven.; Intramuscular steroid injection for treatment of back pain and neck pain: experimental, investigational, or unproven.; Intravenous administration of corticosteroids, lidocaine, magnesium, or vitamin B12 (cyanocobalamin) for treatment of back pain and neck pain: experimental, investigational, or unproven.; ION procedure (Ion Facet Screw System): experimental, investigational, or unproven.; Khan kinetic treatment (KKT): experimental, investigational, or unproven.; Laser facet denervation: experimental, investigational, or unproven.; LigaPASS System for use as a ligament augmentation technique in spinal fusions: experimental, investigational, or unproven.; Least invasive lumbar decompression interbody fusion (LINDIF): experimental, investigational, or unproven.; Magnetic resonance imaging-guided focused ultrasound (MRgFUS) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Microendoscopic discectomy (MED; lumbar endoscopic discectomy utilizing microscope) for decompression of lumbar spine stenosis, lumbar disc herniation, or other indications: experimental, investigational, or unproven.; Microsurgical anterior foraminotomy for cervical spondylotic myelopathy or other indications: experimental, investigational, or unproven.; Minimally invasive/endoscopic cervical laminoforaminotomy for cervical radiculopathy/lateral and foraminal cervical disc herniations or other indications: experimental, investigational, or unproven.; Minimally invasive lumbar decompression (MILD) procedure (percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements under indirect image guidance) for lumbar canal stenosis or other indications: experimental, investigational, or unproven.; Minimally invasive thoracic discectomy for treatment of back pain: experimental, investigational, or unproven.; Minimally invasive endoscopic transforaminal lumbar interbody fusion (endoscopic MITLIF; endoscopic MAST fusion) for lumbar disc degeneration and instability or other indications: experimental, investigational, or unproven.; OptiMesh grafting system: experimental, investigational, or unproven.; Percutaneous cement discoplasty for treatment of lumbar degenerative diseases: experimental, investigational, or unproven.; Percutaneous cervical and lumbar diskectomy: experimental, investigational, or unproven.; Percutaneous endoscopic diskectomy with or without laser (PELD) (arthroscopic microdiskectomy or Yeung Endoscopic Spinal Surgery System [Y.E.S.S.]): experimental, investigational, or unproven.; Percutaneous lumbar discectomy (manual or automated) for treatment of degenerative disc disease: experimental, investigational, or unproven.; Piriformis muscle resection and other surgery for piriformis syndrome: experimental, investigational, or unproven.; Platelet-rich plasma for facet joint injections: experimental, investigational, or unproven.; Posterior intrafacet implants (e.g., DTRAX Cervical Cage) for posterior cervical fusion: experimental, investigational, or unproven.; Psoas compartment block for lumbar radiculopathy or myositis ossification: experimental, investigational, or unproven.; Puborectalis and iliococcygeus trigger point injections for treatment of pelvic pain: experimental, investigational, or unproven.; Racz procedure (epidural adhesiolysis with Racz catheter) for treatment of members with adhesive arachnoiditis, epidural adhesions, failed back syndrome from multiple previous surgeries for herniated lumbar disk, or other indications: experimental, investigational, or unproven.; Radiofrequency denervation for sacroiliac joint pain: experimental, investigational, or unproven.; Radiofrequency lesioning of dorsal root ganglia for back pain: experimental, investigational, or unproven.; Radiofrequency lesioning of terminal (peripheral) nerve endings for back pain: experimental, investigational, or unproven.; Radiofrequency/pulsed radiofrequency ablation of trigger point pain: experimental, investigational, or unproven.; Sacroiliac ligament injection for treatment of unspecified dorsalgia: experimental, investigational, or unproven.; Sacroplasty for osteoporotic sacral insufficiency fractures and other indications: experimental, investigational, or unproven.; Tendon and/or tendon sheath injections for the spine: experimental, investigational, or unproven.; Tendon sheath injections for treatment of back pain: experimental, investigational, or unproven.; Therapeutic facet joint injections: experimental, investigational, or unproven.; Total Facet Arthroplasty System (TFAS) for treatment of spinal stenosis: experimental, investigational, or unproven.; Transforaminal percutaneous endoscopic discectomy for treatment of discogenic low back pain: experimental, investigational, or unproven.; Ultrasound guidance of epidural injections: experimental, investigational, or unproven.; Ultrasound guidance of facet injections: experimental, investigational, or unproven.; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven.; Vesselplasty (e.g., Vessel-X): experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Back Pain - Invasive Procedures?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. The bulletin provides no specific list of procedures requiring precertification and no detailed submission instructions, contact information, or process steps beyond directing clinicians to the CPT code search tool. Documentation: For sacroiliac joint fusion (nicotine cessation, recent nicotine users): a lab report — not a surgeon summary — showing blood or urinary nicotine level ≤10 ng/ml (or urinary cotinine ≤10 ng/ml) drawn within 6 weeks prior to surgery.; For vertebroplasty/kyphoplasty in osteoporotic fractures: documentation for continuum of care for an evaluation of bone mineral density and osteoporosis education for subsequent treatment as indicated, and that the member was instructed to participate in an osteoporosis prevention/treatment program.; For sacroiliac joint injections/fusion: clinician documentation that other neighboring motion segments were evaluated and ruled out as potential pain generators, including diagnostic testing with facet/medial branch blocks and/or interlaminar epidural injections as appropriate based on presentation.; For sacroiliac joint fusion: recent (within 6 months) diagnostic imaging studies including plain X-rays and/or cross-sectional imaging (CT or MRI) of the pelvis, plain X-rays of the pelvis including the ipsilateral hip, and cross-sectional imaging (CT or MRI) of the lumbar spine.; For radiofrequency facet denervation: documentation of two positive diagnostic facet joint injections (intra-articular or medial branch blocks) at the level to be treated, with at least 80% relief of facet-mediated pain for at least the expected minimum duration of the local anesthetic used.; For coccygectomy: documentation of a contraindication where NSAID treatment is not used.
What does Aetna exclude for Back Pain - Invasive Procedures?
Policy exclusions and limitations: Additional sets of facet injections or medial branch blocks at the same levels and side: experimental, investigational, or unproven (no proven value).; Diagnostic facet joint injections NOT medically necessary where radiofrequency facet neurolysis is NOT being considered.; Diagnostic facet joint injections experimental, investigational, or unproven for neck and back pain with untreated radiculopathy.; Facet joint injections (intra-articular and medial branch blocks) containing corticosteroids are considered therapeutic injections only.; Facet joint injections as therapy for back and neck pain and all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of facet injections: experimental, investigational, or unproven (insufficient evidence).; Additional sets of trigger point injections NOT medically necessary if no clinical response achieved.; Trigger point injections for all other indications: experimental, investigational, or unproven (effectiveness not established for other indications).; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven (insufficient evidence).; Ultrasound guidance of sacroiliac joint injections: NOT medically necessary.; Sacroiliac joint injections for all other indications: experimental, investigational, or unproven (effectiveness not established).; Ultrasound guidance of epidural injections: experimental, investigational, or unproven (insufficient evidence).; Interlaminar epidural injections for non-specific low back pain (LBP) and failed back syndrome: experimental, investigational, or unproven (effectiveness not established).; Additional interlaminar epidural injections per region per rolling 12-month period beyond the allowed maximum: NOT medically necessary; experimental, investigational, or unproven (no proven value).; Non-pulsed radiofrequency facet denervation for all other indications: experimental, investigational, or unproven (effectiveness not established).; Interspinous or interlaminar distraction or stabilization devices, with or without lumbar laminectomy and/or fusion: experimental, investigational, or unproven.; CoFix for interlaminar/interspinous stabilization: experimental, investigational, or unproven.; Spine cages otherwise NOT medically necessary for cervical fusion (not proven more effective than bone graft).; Spine cages and structural allograft for indications other than interbody fusion: experimental, investigational, or unproven (effectiveness not established).; Expandable cages for all other indications: experimental, investigational, or unproven.; Vertebroplasty/kyphoplasty/SpineJack for all other indications (other than those listed as medically necessary): experimental, investigational, or unproven.; Sacroiliac joint fusions for all other indications: experimental, investigational, or unproven (effectiveness not established).; Posterior non-transfixing sacroiliac joint fixations, or use of additional joint implants with a transfixing device ('hybrid' fusions): experimental, investigational, or unproven (insufficient evidence and long-term outcomes).; AccuraScope procedure: experimental, investigational, or unproven.; AnchorKnot Tissue Approximation Kit (Anchor Orthopedics) for lumbar discectomy: experimental, investigational, or unproven.; Annulus repair devices (Xclose Tissue Repair System, Barricaid, Disc Annular Repair Technology (DART) System): experimental, investigational, or unproven.; BacFast HD for isolated facet fusion: experimental, investigational, or unproven.; Biomet Aspen fusion system (an interlaminar fixation device): experimental, investigational, or unproven.; Chemical ablation (including but not limited to alcohol, phenol, or sodium morrhuate) of facet joints: experimental, investigational, or unproven.; Chymopapain chemonucleolysis, for all indications, including acute LBP alone, cauda equina syndrome, herniated discs, multiple back operations (failed back surgery syndrome), neurologic disease (e.g., multiple sclerosis), pregnancy, profound or rapidly progressive neurologic deficit, sciatica due to herniated disc, sequestered disc fragment, severe spinal stenosis, severe spondylolisthesis, spinal cord tumor, spinal instability, and when performed with chondroitinase ABC or agents other than chymopapain: experimental, investigational, or unproven.; Coccygeal ganglion (ganglion impar) block for coccydynia, pelvic pain, and all other indications: experimental, investigational, or unproven.; Cooled radiofrequency ablation (e.g., Coolief) for facet denervation: experimental, investigational, or unproven.; Cryoablation (cryoanesthesia, cryodenervation, cryoneurolysis, or cryosurgery) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Custom (patient-specific) synthetic cages/spacers (e.g., Carlsmed Aprevo) for spinal fusion: experimental, investigational, or unproven.; Deuk Laser Disc Repair: experimental, investigational, or unproven.; Devices for annular repair (e.g., Inclose Surgical Mesh System): experimental, investigational, or unproven.; Direct visual rhizotomy (extradural transection or avulsion of other spinal nerve) for chronic low back pain: experimental, investigational, or unproven.; Disc-FX System for treatment (disc decompression, ablation, or annular modulation) of contained disc herniations in cervical, thoracic, and lumbar spine: experimental, investigational, or unproven.; DiscoGel (intradiscal alcohol injection) for treatment of back and neck pain: experimental, investigational, or unproven.; Discseel procedure (regenerative spine procedure) for treatment of back pain: experimental, investigational, or unproven.; Dynamic (intervertebral) stabilization (e.g., BioFlex, CD Horizon Agile Dynamic Stabilization Device, DSS Dynamic Soft Stabilization System, Dynabolt Dynamic Stabilization System, Dynesys Spinal System, Graf ligamentoplasty/Graf artificial ligament, Isobar Spinal System, NFix, Satellite Spinal System, Stabilimax NZ Dynamic Spine Stabilization System, and Zodiak DynaMo System): experimental, investigational, or unproven.; Endoscopic laser foraminoplasty, endoscopic foraminotomy, laminotomy, and rhizotomy (endoscopic radiofrequency ablation): experimental, investigational, or unproven.; Endoscopic transforaminal diskectomy: experimental, investigational, or unproven.; Epidural fat grafting during lumbar decompression laminectomy/discectomy: experimental, investigational, or unproven.; Epidural injections of lytic agents (e.g., hyaluronidase, hypertonic saline) or mechanical lysis in treatment of adhesive arachnoiditis, epidural fibrosis, failed back syndrome, or other indications: experimental, investigational, or unproven.; Epidural steroid injections for treatment of non-radicular low back pain: experimental, investigational, or unproven.; Epiduroscopy (also known as epidural myeloscopy, epidural spinal endoscopy, myeloscopy, and spinal endoscopy) for diagnosis and treatment of intractable LBP or other indications: experimental, investigational, or unproven.; Facet chemodenervation/chemical facet neurolysis: experimental, investigational, or unproven.; Facet joint allograft implants (NuFix facet fusion, TruFuse facet fusion): experimental, investigational, or unproven.; Facet joint implantation (Total Posterior-element System (TOPS) (Premia Spine), Total Facet Arthroplasty System (TFAS) (Archus Orthopedics), ACADIA Facet Replacement System (Facet Solutions/Globus Medical)): experimental, investigational, or unproven.; Far lateral microendoscopic diskectomy (FLMED) for extra-foraminal lumbar disc herniations or other indications: experimental, investigational, or unproven.; Fluoroscopic guidance for trigger point injection: experimental, investigational, or unproven.; Hardware injections/blocks: experimental, investigational, or unproven.; iFuse Bedrock Granite Implant System: experimental, investigational, or unproven.; Injection of steroid into the ilio-lumbar ligament for treatment of low back pain (LBP): experimental, investigational, or unproven.; Interlaminar lumbar instrumented fusion (ILIF): experimental, investigational, or unproven.; Interspinous and interlaminar distraction devices: experimental, investigational, or unproven.; Interspinous fixation devices (Benefix Interspinous Fixation System, CD HORIZON SPIRE Plate, PrimaLOK SP, SP-Fix Spinous Process Fixation Plate, and Stabilink interspinous fixation device) for spinal stenosis or other indications: experimental, investigational, or unproven.; Intracept System (intra-osseous basivertebral nerve ablation) for treatment of low back pain and neck pain: experimental, investigational, or unproven.; Intradiscal injection of local anesthetic for treatment of low back pain: experimental, investigational, or unproven.; Intradiscal injection of notochordal cell-derived matrix for treatment of intervertebral disc disease: experimental, investigational, or unproven.; Intradiscal injection of platelet-rich plasma: experimental, investigational, or unproven.; Intradiscal injection of steroid: experimental, investigational, or unproven.; Intradiscal, paravertebral, or epidural oxygen or ozone injections: experimental, investigational, or unproven.; Intramuscular steroid injection for treatment of back pain and neck pain: experimental, investigational, or unproven.; Intravenous administration of corticosteroids, lidocaine, magnesium, or vitamin B12 (cyanocobalamin) for treatment of back pain and neck pain: experimental, investigational, or unproven.; ION procedure (Ion Facet Screw System): experimental, investigational, or unproven.; Khan kinetic treatment (KKT): experimental, investigational, or unproven.; Laser facet denervation: experimental, investigational, or unproven.; LigaPASS System for use as a ligament augmentation technique in spinal fusions: experimental, investigational, or unproven.; Least invasive lumbar decompression interbody fusion (LINDIF): experimental, investigational, or unproven.; Magnetic resonance imaging-guided focused ultrasound (MRgFUS) for treatment of lumbar facet joint pain: experimental, investigational, or unproven.; Microendoscopic discectomy (MED; lumbar endoscopic discectomy utilizing microscope) for decompression of lumbar spine stenosis, lumbar disc herniation, or other indications: experimental, investigational, or unproven.; Microsurgical anterior foraminotomy for cervical spondylotic myelopathy or other indications: experimental, investigational, or unproven.; Minimally invasive/endoscopic cervical laminoforaminotomy for cervical radiculopathy/lateral and foraminal cervical disc herniations or other indications: experimental, investigational, or unproven.; Minimally invasive lumbar decompression (MILD) procedure (percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements under indirect image guidance) for lumbar canal stenosis or other indications: experimental, investigational, or unproven.; Minimally invasive thoracic discectomy for treatment of back pain: experimental, investigational, or unproven.; Minimally invasive endoscopic transforaminal lumbar interbody fusion (endoscopic MITLIF; endoscopic MAST fusion) for lumbar disc degeneration and instability or other indications: experimental, investigational, or unproven.; OptiMesh grafting system: experimental, investigational, or unproven.; Percutaneous cement discoplasty for treatment of lumbar degenerative diseases: experimental, investigational, or unproven.; Percutaneous cervical and lumbar diskectomy: experimental, investigational, or unproven.; Percutaneous endoscopic diskectomy with or without laser (PELD) (arthroscopic microdiskectomy or Yeung Endoscopic Spinal Surgery System [Y.E.S.S.]): experimental, investigational, or unproven.; Percutaneous lumbar discectomy (manual or automated) for treatment of degenerative disc disease: experimental, investigational, or unproven.; Piriformis muscle resection and other surgery for piriformis syndrome: experimental, investigational, or unproven.; Platelet-rich plasma for facet joint injections: experimental, investigational, or unproven.; Posterior intrafacet implants (e.g., DTRAX Cervical Cage) for posterior cervical fusion: experimental, investigational, or unproven.; Psoas compartment block for lumbar radiculopathy or myositis ossification: experimental, investigational, or unproven.; Puborectalis and iliococcygeus trigger point injections for treatment of pelvic pain: experimental, investigational, or unproven.; Racz procedure (epidural adhesiolysis with Racz catheter) for treatment of members with adhesive arachnoiditis, epidural adhesions, failed back syndrome from multiple previous surgeries for herniated lumbar disk, or other indications: experimental, investigational, or unproven.; Radiofrequency denervation for sacroiliac joint pain: experimental, investigational, or unproven.; Radiofrequency lesioning of dorsal root ganglia for back pain: experimental, investigational, or unproven.; Radiofrequency lesioning of terminal (peripheral) nerve endings for back pain: experimental, investigational, or unproven.; Radiofrequency/pulsed radiofrequency ablation of trigger point pain: experimental, investigational, or unproven.; Sacroiliac ligament injection for treatment of unspecified dorsalgia: experimental, investigational, or unproven.; Sacroplasty for osteoporotic sacral insufficiency fractures and other indications: experimental, investigational, or unproven.; Tendon and/or tendon sheath injections for the spine: experimental, investigational, or unproven.; Tendon sheath injections for treatment of back pain: experimental, investigational, or unproven.; Therapeutic facet joint injections: experimental, investigational, or unproven.; Total Facet Arthroplasty System (TFAS) for treatment of spinal stenosis: experimental, investigational, or unproven.; Transforaminal percutaneous endoscopic discectomy for treatment of discogenic low back pain: experimental, investigational, or unproven.; Ultrasound guidance of epidural injections: experimental, investigational, or unproven.; Ultrasound guidance of facet injections: experimental, investigational, or unproven.; Ultrasound or electromyography (EMG) guidance of trigger point injections: experimental, investigational, or unproven.; Vesselplasty (e.g., Vessel-X): experimental, investigational, or unproven. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0016 — Back Pain - Invasive Procedures

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This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0016 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.