Aetna Selective Nerve Root Blocks coverage criteria

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.

Coverage criteria

• Diagnostic selective transforaminal epidural steroid injections (TFESIs), performed with imaging guidance (fluoroscopy or CT), are medically necessary to identify the etiology of pain in members with symptoms suggestive of chronic radiculopathy where the diagnosis remains uncertain after standard evaluation, when ANY ONE of the following applies: (a) pain appears to be a classic mono-radiculopathy but radiological/neuro-diagnostic studies fail to provide a structural explanation; OR (b) classic mono-radicular pain exists with a radiological abnormality related to an adjacent nerve root only; OR (c) the clinical picture is suggestive but not typical for both nerve root and distal nerve/joint disease.
• Initial therapeutic TFESI, performed with imaging guidance (fluoroscopy or CT), is medically necessary for members with radiculopathy when ALL of the following are met: non-invasive measures (physical therapy, non-narcotic analgesics) have failed or caused intolerance, AND the member has radicular pain consistent with the radiologic findings.
• Additional (repeat) therapeutic TFESIs are medically necessary only if the initial injection resulted in AT LEAST TWO of the following for at least 2 weeks: (1) 50% or greater relief in pain; (2) increase in level of function/physical activity (e.g., return to work); (3) reduction in pain medication use and/or additional medical treatment (physical therapy/chiropractic care).
• Therapeutic TFESIs must be administered as part of a comprehensive pain management program.
• Frequency/volume limit (single session): a maximum of two (2) contiguous vertebral levels or four (4) TFESIs per single session is medically necessary.
• Frequency limit (per episode/6 months): a maximum of three (3) TFESI sessions per episode of pain, per spinal region, per six (6) months is medically necessary.
• Volume limit (per episode/6 months): a maximum of twelve (12) TFESIs per spinal region during the maximum of three (3) sessions for an episode lasting six (6) months is medically necessary.
• Frequency limit (per 12 months): a maximum of four (4) sessions per spinal region per twelve (12) months is medically necessary.
• Interval limit: a minimum of two (2) weeks must elapse between TFESI sessions.
• Radiculopathy is defined as pain, dysaesthesias, or paraesthesias in a specified dermatomal distribution causing significant functional limitations, PLUS EITHER (a) documentation of nerve root compression with concordant findings (loss of strength, altered sensation, diminished reflexes) on a detailed neurologic examination performed within the prior three (3) months; OR (b) documentation within the prior 12 months of either concordant advanced imaging (MRI/CT) or electrodiagnostic studies (EMG/NCV) diagnostic of nerve root compression.

Covered codes

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

• 64479·PA verdict·Rate
• 64480·PA verdict·Rate
• 64483·PA verdict·Rate
• 64484·PA verdict·Rate

Documentation required

• Documentation supporting the radiculopathy diagnosis: EITHER a detailed neurologic examination within the prior three (3) months demonstrating concordant nerve root compression findings (loss of strength, altered sensation, diminished reflexes); OR advanced imaging (MRI/CT) or electrodiagnostic studies (EMG/NCV) within the prior 12 months documenting nerve root compression.
• Documentation of the member's response to the initial injection (at least two of: >=50% pain relief, increased function, reduced medication/treatment, sustained for at least 2 weeks) is required to support coverage of additional/repeat therapeutic TFESIs.

Frequently asked questions

When does Aetna cover Selective Nerve Root Blocks (CPT 64479), and what gets it denied?

Aetna CPB 0722 covers imaging-guided (fluoroscopy or CT) transforaminal epidural steroid injections (TFESIs): diagnostically when a radiculopathy diagnosis remains uncertain after standard workup, and therapeutically for documented radiculopathy after conservative measures fail, with repeat injections requiring a documented response to the initial injection. Coverage is bounded by strict level, volume, frequency, and interval limits (e.g., max 2 contiguous levels / 4 injections per session, max 3 sessions per 6 months, min 2 weeks between sessions), and several combination, ultrasound-guided, and off-indication uses are deemed experimental/investigational or not medically necessary. Coverage criteria include: Diagnostic selective transforaminal epidural steroid injections (TFESIs), performed with imaging guidance (fluoroscopy or CT), are medically necessary to identify the etiology of pain in members with symptoms suggestive of chronic radiculopathy where the diagnosis remains uncertain after standard evaluation, when ANY ONE of the following applies: (a) pain appears to be a classic mono-radiculopathy but radiological/neuro-diagnostic studies fail to provide a structural explanation; OR (b) classic mono-radicular pain exists with a radiological abnormality related to an adjacent nerve root only; OR (c) the clinical picture is suggestive but not typical for both nerve root and distal nerve/joint disease.; Initial therapeutic TFESI, performed with imaging guidance (fluoroscopy or CT), is medically necessary for members with radiculopathy when ALL of the following are met: non-invasive measures (physical therapy, non-narcotic analgesics) have failed or caused intolerance, AND the member has radicular pain consistent with the radiologic findings.; Additional (repeat) therapeutic TFESIs are medically necessary only if the initial injection resulted in AT LEAST TWO of the following for at least 2 weeks: (1) 50% or greater relief in pain; (2) increase in level of function/physical activity (e.g., return to work); (3) reduction in pain medication use and/or additional medical treatment (physical therapy/chiropractic care).; Therapeutic TFESIs must be administered as part of a comprehensive pain management program.; Frequency/volume limit (single session): a maximum of two (2) contiguous vertebral levels or four (4) TFESIs per single session is medically necessary.; Frequency limit (per episode/6 months): a maximum of three (3) TFESI sessions per episode of pain, per spinal region, per six (6) months is medically necessary.; Volume limit (per episode/6 months): a maximum of twelve (12) TFESIs per spinal region during the maximum of three (3) sessions for an episode lasting six (6) months is medically necessary.; Frequency limit (per 12 months): a maximum of four (4) sessions per spinal region per twelve (12) months is medically necessary.; Interval limit: a minimum of two (2) weeks must elapse between TFESI sessions.; Radiculopathy is defined as pain, dysaesthesias, or paraesthesias in a specified dermatomal distribution causing significant functional limitations, PLUS EITHER (a) documentation of nerve root compression with concordant findings (loss of strength, altered sensation, diminished reflexes) on a detailed neurologic examination performed within the prior three (3) months; OR (b) documentation within the prior 12 months of either concordant advanced imaging (MRI/CT) or electrodiagnostic studies (EMG/NCV) diagnostic of nerve root compression.. Applies to 4 codes: 64479, 64480, 64483, 64484. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation supporting the radiculopathy diagnosis: EITHER a detailed neurologic examination within the prior three (3) months demonstrating concordant nerve root compression findings (loss of strength, altered sensation, diminished reflexes); OR advanced imaging (MRI/CT) or electrodiagnostic studies (EMG/NCV) within the prior 12 months documenting nerve root compression.; Documentation of the member's response to the initial injection (at least two of: >=50% pain relief, increased function, reduced medication/treatment, sustained for at least 2 weeks) is required to support coverage of additional/repeat therapeutic TFESIs. Policy exclusions and limitations: Experimental/investigational/unproven: Combined pulsed radiofrequency and transforaminal epidural steroid injection for the treatment of herpes zoster (HZ)-related pain.; Experimental/investigational/unproven: Combined pulsed radiofrequency and transforaminal epidural steroid injection for the treatment of lumbar radiculopathy.; Experimental/investigational/unproven: Diagnostic TFESIs for all other indications not listed in Section I (covered criteria).; Experimental/investigational/unproven: Intra-operative administration of epidural steroids following percutaneous transforaminal endoscopic discectomy.; Experimental/investigational/unproven: TFESI combined with radiofrequency ablation for the treatment of lumbar disc herniation.; Experimental/investigational/unproven: Therapeutic TFESIs for all other indications not listed in Section I (covered criteria).; Experimental/investigational/unproven: Transforaminal or interlaminar epidural steroid injections combined with caudal epidural steroid injections for the treatment of chronic radicular pain.; Experimental/investigational/unproven: Ultrasound-guided transforaminal epidural steroid injections.; Not medically necessary: TFESIs at more than two (2) contiguous vertebral levels, or more than four (4) TFESIs, in a single session.; Not medically necessary: More than three (3) TFESI sessions per episode of pain, per spinal region, per six (6) months.; Not medically necessary: More than four (4) sessions of TFESIs per spinal region per twelve (12) months.; Not medically necessary: TFESI sessions performed more frequently than every two (2) weeks. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Selective Nerve Root Blocks?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation supporting the radiculopathy diagnosis: EITHER a detailed neurologic examination within the prior three (3) months demonstrating concordant nerve root compression findings (loss of strength, altered sensation, diminished reflexes); OR advanced imaging (MRI/CT) or electrodiagnostic studies (EMG/NCV) within the prior 12 months documenting nerve root compression.; Documentation of the member's response to the initial injection (at least two of: >=50% pain relief, increased function, reduced medication/treatment, sustained for at least 2 weeks) is required to support coverage of additional/repeat therapeutic TFESIs.

What does Aetna exclude for Selective Nerve Root Blocks?

Policy exclusions and limitations: Experimental/investigational/unproven: Combined pulsed radiofrequency and transforaminal epidural steroid injection for the treatment of herpes zoster (HZ)-related pain.; Experimental/investigational/unproven: Combined pulsed radiofrequency and transforaminal epidural steroid injection for the treatment of lumbar radiculopathy.; Experimental/investigational/unproven: Diagnostic TFESIs for all other indications not listed in Section I (covered criteria).; Experimental/investigational/unproven: Intra-operative administration of epidural steroids following percutaneous transforaminal endoscopic discectomy.; Experimental/investigational/unproven: TFESI combined with radiofrequency ablation for the treatment of lumbar disc herniation.; Experimental/investigational/unproven: Therapeutic TFESIs for all other indications not listed in Section I (covered criteria).; Experimental/investigational/unproven: Transforaminal or interlaminar epidural steroid injections combined with caudal epidural steroid injections for the treatment of chronic radicular pain.; Experimental/investigational/unproven: Ultrasound-guided transforaminal epidural steroid injections.; Not medically necessary: TFESIs at more than two (2) contiguous vertebral levels, or more than four (4) TFESIs, in a single session.; Not medically necessary: More than three (3) TFESI sessions per episode of pain, per spinal region, per six (6) months.; Not medically necessary: More than four (4) sessions of TFESIs per spinal region per twelve (12) months.; Not medically necessary: TFESI sessions performed more frequently than every two (2) weeks. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT