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CIGNA MEDICAL POLICIES

 

MINIMALLY INVASIVE TREATMENT OF BACK AND NECK PAIN   Policy 0139  Effective 7/11

 

Coverage Policy

 

Trigger Point Injection 

CIGNA covers initial trigger-point injection(s) of anesthetic and/or corticosteroid (CPT codes 20552,

20553) for subacute or chronic back, or neck pain, or subacute or chronic myofascial pain syndrome as

medically necessary when pain has persisted despite appropriate conservative treatment (e.g.,

pharmacological therapy, physical therapy, exercise). 

CIGNA covers repeat trigger-point injection(s) of anesthetic and/or corticosteroid as medically

necessary if improvement following the initial injection(s) is unsatisfactory, to determine whether trigger

point injection(s) may provide therapeutic benefit.

CIGNA covers additional trigger-point injections of anesthetic and/or corticosteroid for subacute or

chronic back pain, neck pain, or myofascial pain syndrome as medically necessary when the prior

injection resulted in subjective and objective improvement (e.g., improvement in pain, functioning,

activity tolerance) and BOTH of the following criteria are met:

• A minimum of three weeks has elapsed since the prior injection

• Injections are provided in conjunction with an active therapy program, including a home exercise

program.

 

CIGNA does not cover long-term, repeated or maintenance trigger point injection for any indication

because it is considered not medically necessary.

CIGNA does not cover dry needling of trigger points for any indication because it is considered

experimental, investigational, or unproven.

CIGNA does not cover ultrasound guidance (76942) for trigger point injections for any indication

because it is considered not medically necessary.

 

Epidural Steroid Injection/Selective Nerve Root Block 

CIGNA covers epidural steroid injection/selective nerve root block (CPT codes 62310, 62311, 64479-

64484, 77003) as medically necessary for the treatment of acute or recurrent cervical, thoracic or lumbar

radicular pain (e.g. sciatica) when improvement is not seen following at least three weeks of

conservative management (e.g., pharmacological therapy, physical therapy, exercise). 

CIGNA covers up to two subsequent epidural steroid injections/selective nerve root blocks block as

medically necessary when there was at least three weeks of temporary, partial relief of symptoms

following the prior injection, but radicular pain has persisted or worsened.

CIGNA does not cover long-term, repeated or maintenance epidural steroid injection /selective nerve

root block for any indication because it is considered not medically necessary.

CIGNA does not cover EITHER of the following because each is considered experimental,

investigational or unproven:

• Epidural steroid injection/selective nerve root block for acute, subacute, or chronic back pain

• Epidural steroid injection with ultrasound guidance (0231T, 0232T) for any indication

 

Intradiscal Steroid Injection 

CIGNA does not cover intradiscal steroid injection for the treatment of acute, subacute, or chronic back

or neck pain because it is considered experimental, investigational, or unproven.

 

Facet Joint Injection 

CIGNA covers a diagnostic facet joint injection (CPT codes  64490-64495) as medically necessary when

used to determine whether chronic neck or back pain is of facet joint origin when ALL of the following

criteria are met:

• Pain is exacerbated by extension and rotation, or is associated with lumbar rigidity

• Pain has persisted despite appropriate conservative treatment (e.g., nonsteroidal anti-inflammatory

drugs (NSAIDs, exercise)

• Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., spinal stenosis,

disc degeneration or herniation, infection, tumor, fracture)

CIGNA does not cover therapeutic facet joint injection (CPT codes 64490-64495) for the treatment of

acute, subacute, or chronic neck or back pain or radicular syndromes because it is considered

experimental, investigational, or unproven.

CIGNA does not cover diagnostic or therapeutic facet joint injection with ultrasound guidance (CPT

codes 0213T-0218T) for any indication because it is considered experimental, investigational, or

unproven.

 

Sacroiliac (SI) Joint Injection 

CIGNA covers SI joint injection (CPT code 27096, HCPCS code G0260)) for the treatment of back pain

associated with localized SI joint pathology (e.g., inflammatory arthritis) confirmed on imaging studies.

CIGNA does not cover EITHER of the following because each is considered experimental,

investigational, or unproven:

• SI joint injection (CPT code 27096) for the diagnosis or treatment of acute, subacute, or chronic back

pain or radicular syndromes

• ultrasound guidance (76942) for SI joint injection for any indication

 

Ablative Treatment 

CIGNA covers initial radiofrequency ablation/neurolysis of paravertebral facet joint nerves (CPT codes

64622-64627, 77003) for the treatment of chronic back or neck pain as medically necessary when ALL of

the following criteria are met:

• There is severe pain unresponsive to at least six months of conservative medical management. (e.g.,

pharmacological therapy, physical therapy, exercise).

• Facet joint origin of pain is suspected and medial branch block/injection of facet joint with local

anesthetic results in elimination or marked decrease in intensity of pain.

• Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., spinal stenosis,

disc degeneration or herniation, infection, tumor, fracture)

 

CIGNA covers repeat radiofrequency ablation/neurolysis of paravertebral facet joint nerves at the same

level for the treatment of chronic back or neck pain as medically necessary when BOTH of the following

criteria are met:

• At least  six months have elapsed since the previous radiofrequency ablation/neurolysis of paravertebral

facet joint nerves

• More than 50% relief is obtained , with associated functional improvement, for at least ten weeks

following the previous treatment

 

CIGNA does not cover long-term, repeated or maintenance radiofrequency ablation/neurolysis of

paravertebral facet joint nerves for any indication because it is considered not medically necessary.

CIGNA does not cover ANY of the following ablative procedures for the treatment of back or neck pain

because each is considered experimental, investigational or unproven (this list may not be all inclusive);

-Pulsed radiofrequency (CPT code 64999)

-Cryoablation/cryoneurolysis/cryodenervation (CPT code 64999)

-Chemical ablation (e.g., alcohol, phenol, glycerol) (CPT codes 64622-64627)

-Laser ablation (CPT code 64999)

-Sacroiliac (SI) joint ablation by any method (CPT code 64640)

 

Other Procedures 

CIGNA does not cover ANY of the following procedures because each is considered experimental,

investigational or unproven (this list may not be all-inclusive): 

• automated percutaneous lumbar discectomy (APLD)/automated percutaneous nucleotomy (CPT code

62287, HCPS codes C2614)

• Coblation®Nucleoplasty™ disc nucleoplasty, decompression nucleoplasty plasma disc decompression 

(CPT code 62287)

• devices for anular repair (e.g., Inclose™ Surgical Mesh System, Xclose™ Tissue Repair System

(Anulex Technologies, Inc., Minnetonka, MN)

• endoscopic epidural adhesiolysis  (CPT code 64999)

• epiduroscopy, epidural myeloscopy, epidural spinal endoscopy (CPT code 64999)

• intervertebral disc biacuplasty (CPT code 22899)

• intradiscal electrothermal annuloplasty (e.g., intradiscal electrothermal therapy [IDET™])

• percutaneous laminotomy/laminectomy, percutaneous spinal decompression (e.g., mild®

 procedure) (CPT codes 22899, 64999, 0274T, 0275T, HCPCS code C9729))

• percutaneous laser discectomy /decompression, laser-assisted disc decompression (LADD) (CPT code

62287) 

• percutaneous epidural adhesiolysis, percutaneous epidural lysis of adhesions, Racz procedure (CPT

codes 62263, 62264)

• percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), intradiscal radiofrequency

thermomodulation or percutaneous radiofrequency thermomodulation (CPT codes 22526, 22527,

HCPCS code S2348)

 

DISCOGRAPHY  Policy 0393   Effective 1/11

Coverage Policy

CIGNA covers lumbar provocative discography, including post discography computed tomography (CT)

assessment, as medically necessary for the preoperative evaluation of discogenic back pain, when ALL

of the following criteria for a single level lumbar fusion have been met:

• unremitting pain with significant functional impairment of at least twelve months duration

• failure of at least six (6) consecutive months of structured*, physician-supervised conservative medical

management, which includes ALL of the following components: 

- exercise, including core stabilization exercises

- analgesics, nonsteroidal anti-inflammatory medication, unless contraindicated 

- physical therapy, including passive and active treatment modalities

- activity/lifestyle modification

- cognitive therapy

• complex imaging studies (e.g., computerized tomography (CT) scan or magnetic resonance imaging

(MRI) scan) do not conclusively demonstrate single level degenerative disc disease as the likely cause

of pain

• documentation from a primary care physician, neurologist, physiatrist,  psychiatrist or psychologist

supports absence of untreated, underlying psychological conditions/issues (e.g., depression, drug and

alcohol abuse) as a contributor to chronic pain

*Note: Structured medical management consists of medical care that is delivered through

regularly scheduled appointments, including follow-up evaluation, with licensed healthcare

professionals. 

 

CIGNA does not cover discography (e.g., provocative discography, stimulation discography) with or

without CT assessment, when performed in connection with or in anticipation of any procedure that has

been determined to be experimental, investigational or unproven, including, but not limited to ANY of

the following:

• intradiscal electrothermal therapy (IDET)

• disc nucleoplasty, decompression nucleoplasty, or Coblation® Nucleoplasty™

• laser discectomy (e.g., percutaneous, laparoscopic)

CIGNA does not cover any of the following because each is considered experimental, investigational or

unproven (This list may not be all-inclusive):

• cervical discography

• thoracic discography

• functional anesthetic discography (FAD)

• contrast disc analysis mapping

 

 

LOCAL ANESTHESIA INJECTIONS AND NEUROSURGERY FOR CERVICOGENIC AND OCCIPITAL

HEADACHES

Policy 0063   Effective 04/11

Coverage Policy

CIGNA does not cover ANY of the following local injection therapies or neurosurgeries for the treatment

of cervicogenic headache or occipital neuralgia because these interventions are considered

experimental, investigational or unproven (this list may not be all-inclusive): 

• botulinum toxin type A*

• cervical microdecompression surgery (Jho Procedure)

• discectomy and spinal fusion

• electrical stimulation of occipital nerve

• ganglionectomy

• nerve root decompression

• neurectomy

• occipital nerve neurolysis

• radiofrequency denervation of cervical facet joints

• radiofrequency ablation of the planum nuchale

• rhizotomy

 

PERCUTANEOUS VERTEBROPLASTY/KYPHOPLASTY/SACROPLASTY

Policy 0040  Effective 4/11

Coverage Policy

CIGNA covers percutaneous kyphoplasty as medically necessary when standard medical therapy has

failed to alleviate symptoms and ANY of the following criteria is met:

• osteoporotic, osteolytic, osteonecrotic (i.e., Kummell disease), or steroid-induced vertebral compression

fracture with persistent, debilitating pain unresponsive to at least six weeks of conservative medical

management

• severe back pain secondary to destruction of vertebral body due to osteolytic vertebral metastasis or multiple myeloma

• painful and/or aggressive hemangioma or eosinophlic granuloma of the spine

CIGNA covers percutaneous vertebroplasty as medically necessary when standard medical therapy has

failed to alleviate symptoms and EITHER of the following criteria is met:

• severe back pain secondary to destruction of vertebral body due to osteolytic vertebral metastasis or

multiple myeloma

• painful and/or aggressive hemangioma or eosinophilic granuloma of the spine

CIGNA does not cover percutaneous vertebroplasty or kyphoplasty for any other indication because

each is considered experimental, investigational, or unproven.

CIGNA does not cover percutaneous sacroplasty for any indication because it is considered

experimental, investigational, or unproven.

 

SPINAL CORD STIMULATION

Policy 380  Effective 7/11

CIGNA covers a short-term trial of a lumbar or thoracic dorsal column spinal cord stimulator (SCS) for

the treatment of chronic intractable pain of greater than six months’ duration as medically necessary

when BOTH of the following criteria are met:

• There is failure of available conventional multidisciplinary medical (e.g., pharmacological, physical

therapy) and surgical management.

• An evaluation by a mental health provider (e.g., a face-to-face assessment with or without

psychological questionnaires and/or psychological testing) reveals no evidence of an inadequately

controlled mental heath problem (e.g., alcohol or drug dependence, depression, psychosis) that

would negatively impact the success of a SCS or contraindicate its placement.

CIGNA covers permanent implantation of a lumbar or thoracic dorsal column spinal cord stimulator

(SCS) for the treatment of chronic intractable pain of greater than six months’ duration as medically

necessary when ALL of the following criteria are met:

• There is failure of available conventional multidisciplinary medical (e.g., pharmacological, physical

therapy) and surgical management.

• An evaluation by a mental health provider (e.g., a face-to-face assessment with or without

psychological questionnaires and/or psychological testing) reveals no evidence of an inadequately

controlled mental heath problem (e.g., alcohol or drug dependence, depression, psychosis) that

would negatively impact the success of a SCS or contraindicate its placement.

• Pain relief from a temporarily implanted electrode has been demonstrated prior to permanent

implantation.

CIGNA covers a short-term trial of a lumbar or thoracic dorsal column spinal cord stimulator (SCS) for

the treatment of pain secondary to chronic stable angina pectoris as medically necessary in individuals

with myocardial ischemia when ALL of the following criteria are met: 

• Angina pectoris is Canadian Cardiovascular Society (CCS) functional class III or class IV (see

Appendix A). 

• The individual has documented significant coronary artery disease (CAD) and is not a suitable

candidate for revascularization procedures.

• Optimal pharmacological treatment using anti-anginal medications (e.g., long-acting nitrates, betaadrenergic blockers, or calcium-channel antagonists) has failed to adequately improve anginal

symptoms.

• An evaluation by a mental health provider (e.g., a face-to-face assessment with or without

psychological questionnaires and/or psychological testing) reveals no evidence of an inadequately

controlled mental heath problem (e.g., alcohol or drug dependence, depression, psychosis) that

would negatively impact the success of a SCS or contraindicate its placement.

CIGNA covers permanent implantation of a lumbar or thoracic dorsal column spinal cord stimulator

(SCS) for the treatment of pain secondary to chronic stable angina pectoris as medically necessary in

individuals with myocardial ischemia when ALL of the following criteria are met:

• Angina pectoris is Canadian Cardiovascular Society (CCS) functional class III or class IV (see

Appendix A). 

• The individual has documented significant coronary artery disease (CAD) and is not a suitable

candidate for revascularization procedures.

• Optimal pharmacological treatment using anti-anginal medications (e.g., long-acting nitrates, betaadrenergic blockers, or calcium-channel antagonists) has failed to adequately improve anginal

symptoms.

• An evaluation by a mental health provider (e.g., a face-to-face assessment with or without

psychological questionnaires and/or psychological testing) reveals no evidence of an inadequately

controlled mental heath problem (e.g., alcohol or drug dependence, depression, psychosis) that

would negatively impact the success of a SCS or contraindicate its placement.

• Pain relief from a temporarily implanted electrode has been demonstrated prior to permanent

implantation.

CIGNA does not cover cervical placement of a dorsal column spinal cord stimulator (SCS) for any

indication because it is considered experimental, investigational or unproven.

 

 

IMPLANTABLE INFUSION PUMPS

Policy 0370  Effective 6/11

Coverage Policy

 

CIGNA covers the use of an implantable infusion pump and supplies, when used to administer drugs

that are specifically approved by the U.S. Food and Drug Administration (FDA) for the intended use, as

medically  necessary for EITHER of the following conditions: 

• intrahepatic arterial infusion of chemotherapeutic drugs when the cancer is unresectable or the

individual is not a surgical candidate for EITHER of the following indications: 

-primary hepatocellular cancer

- metastatic cancer that is limited to the liver

• intrathecal administration of anti-spasmodic drugs for the treatment of chronic intractable spasticity or

chronic intractable dystonia when BOTH of the following criteria are met:

- there is failure, contraindication or intolerance to at least a six-week trial of oral antispasmodic

drugs and physical therapy

- history of a of a favorable response to a trial of an intrathecal dose of anti-spasmodic drug  

 

CIGNA covers a short term (i.e., temporary) trial of an implantable infusion pump and supplies  for the

treatment of severe, chronic, intractable pain,  when used to administer drugs that are specifically

approved by the U.S. Food and Drug Administration (FDA) for the intended use,  as medically necessary

for EITHER of the following conditions: 

• cancer-related pain when there is failure of, or intolerance, or contraindications to, noninvasive methods

of pain control, including systemic opioids.

• non cancer-related pain when BOTH of the following criteria are met: 

- failure of, or intolerance, or contraindications to, noninvasive methods of pain control, including

systemic opioids.

- attempts have been made to eliminate physical and behavioral contributors to an exaggerated

sensation of pain.

CIGNA covers a permanent implantable infusion pump for intrathecal or epidural administration of

analgesics for the treatment of severe, chronic, intractable pain conditions when a preliminary trial of

intraspinal opioid drug administration, that meets the above medical necessity criteria, demonstrates

successful pain relief, and individual tolerance and acceptance. 

 

CIGNA does not cover the use of an implantable infusion pump ANY other indication, including the

following, because it is considered experimental, investigational or unproven (this list may not be allinclusive):

• administration of insulin for diabetes

• administration of antibiotics for osteomyelitis

• administration of heparin for thromboembolic disease

 

 

PROLOTHERAPY

Policy 0006  Effective 1/11

Coverage Policy

Prolotherapy is specifically excluded under some benefit plans. Please refer to the applicable benefit

plan document to determine benefit availability and the terms, conditions and limitations of coverage.

 

CIGNA does not cover prolotherapy for any indication because it is considered experimental,

investigational or unproven

 

RSD/CRPS PAIN SYNDROME TREATMENT

Policy 0438  Effective Date 2/11

Coverage Policy

Services provided by a psychiatrist, psychologist or other behavioral health professional are subject to

the provisions of the applicable behavioral health benefit.

Please refer to the CIGNA Coverage Policies on Occupational Therapy and Physical Therapy for specific

coverage criteria for these therapies.

CIGNA covers the following treatments as medically necessary for complex regional pain syndrome

(CRPS) when conventional medical and surgical management have failed to control symptoms:

• spinal cord stimulator

• peripheral nerve stimulator

• intrathecal drug delivery with subcutaneous pump

• sympathectomy

Note: Refer to the CIGNA Coverage Policy Spinal Cord Stimulation for specific criteria on spinal cord

stimulators and the Coverage Policy Implantable Infusion Pumps for specific criteria on implantable

intrathecal or epidural infusion pumps to administer analgesics. 

CIGNA does not cover the following procedures/services for the treatment of CRPS because each is

considered experimental, investigational or unproven for this indication (this list may not be allinclusive):

• acupuncture

• biofeedback

• electromagnetic field treatment 

• hyperbaric oxygen 

• hypnosis

• interferential stimulators

• ketamine administration

• mirror box therapy

• motor cortex stimulation

• radiofrequency ablation

 

 

QUANTITATIVE SENSORY TESTING (QST)

Policy 0268  Effective 12/10

Coverage Policy

CIGNA does not cover ANY quantitative sensory testing (QST) method, including but not limited to the

following, because such testing is considered experimental, investigational, or unproven:

• current perception threshold (CPT) testing

• sensory nerve conduction testing (sNCT)

• pressure-specified sensory testing

• vibration perception threshold testing

• voltage-actuated sensory nerve conduction threshold (V-sNCT) testing

 

SPINAL TRACTION AND EXERCISE DEVICES

Policy 140  Effective 8/11

Coverage Policy

Exercise equipment is specifically excluded under many benefit plans. 

CIGNA does not cover the use of any of the following mechanical devices, because each is considered

experimental, investigational, or unproven for the treatment of any condition (this list may not be allinclusive):

• quantitative muscle testing and treatment devices (e.g., MedX, Isostation B-200, Cybex, Kin-Com, and

Biodex)

• vertebral axial decompression therapy and devices (e.g., VAX-D, DRX, DRX2000, DRX3000, DRX5000,

DRX9000, DRS, Accu-SPINA™ System, IDD Therapy® [Intervertebral Differential Dynamics Therapy],

Tru Tac 401, Lordex Power Traction device, Spinerx LDM) 

• patient-operated spinal unloading devices (e.g., LTX 3000™

, Orthotrac™ Pneumatic Vest)

 

ULTRARAPID OPIOID DETOXIFICATION

Policy  0384  Effective 7/11

Coverage Policy

CIGNA does not cover opioid antagonist agent detoxification under sedation or general anesthesia (e.g.,

ultra-rapid detoxification) as a method for opioid detoxification because it is considered experimental,

investigational or unproven