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Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic single level Pulsed radiofrequency of the dorsal root ganglion, Angiotensin II type 2 receptor antagonist, Thermotherapy (including fire needle, moxibustion) – no specific codeĮxtracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy Lumbar or sacral, each additional level (List separately in addition to code for primary procedure)ĬPT codes not covered for indications listed in the CPB (not all-inclusive):
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Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT) cervical or thoracic, single levelĬervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic Table: CPT Codes / HCPCS Codes / ICD-10 Codes CodeĬPT codes covered if selection criteria are met: CPB 0297 - Cryoanalgesia and Therapeutic Cold.CPB 0115 - Varicella and Herpes Zoster Vaccines.CPB 0011 - Electrical Stimulation for Pain.Refer to applicable pharmacy benefit plan for capsaicin topical (Qutenza).
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Vitamin B-12 injection (see CPB 0536 - Vitamin B-12 Therapy) Use of any of the following pharmacotherapies for treatment of PHN:.Use of gabapentin and low-level laser for prevention of PHN.Transcutaneous electrical nerve stimulation (TENS).Thermotherapy (including fire needle and moxibustion).Pulsed radiofrequency of the dorsal root ganglion.Dorsal root entry zone lesions/dorsal root ganglion destruction.Combination of trigeminal ganglion and retrobulbar nerve block.Combined therapy of nerve block and pulsed radiofrequency.Botulinum toxin (see CPB 0113 - Botulinum Toxin).Angiotensin II type 2 receptor antagonists.This Clinical Policy Bulletin addresses post-herpetic neuralgia.Īetna considers the use of antivirals (oral), gabapentin, intrathecal, interlaminar or transforaminal epidural corticosteroids, lidocaine patch, opioids (oral), pregabalin, and tricyclic anti-depressants medically necessary for post-herpetic neuralgia (PHN).Īetna considers any the following therapeutic modalities for PHN experimental and investigational because their effectiveness for this indication has not been established (not an all-inclusive list): Number: 0725 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References