Spinal Injection Therapies

POLICY

The TAC can fund the reasonable cost of spinal injection therapies for TAC clients when required as a result of their transport accident injuries, and where the treatment is provided by a medical specialist trained in its use.

Transport Accident Act 1986 reference: s.3 'medical service' and s.60

For surgery requests, refer to the Surgery Requests Elective policy and the Hospitals policies.

For discography requests, refer to the Medical Imaging policy.

For Radiofrequency denervation requests, refer to the Radiofrequency Denervation (RFD) policy.

DEFINITIONS

In this policy:

• Spinal injection procedures include injections of local anaesthetic and/or steroid and can be grouped as follows:
  • Epidural injections including spinal nerve root sleeve injection, spinal nerve root injection, spinal nerve root block, periradicular infiltration, perineural injection, dorsal root ganglion nerve injection, dorsal root ganglion injection, dorsal root ganglion block
    • Location can be cervical (neck), thoracic or lumbar spine
  • Medial Branch blocks (Local anaesthetic only)
  • Facet Joint injections (Zygoapophyseal joint injections)
    • Location can be cervical (neck), thoracic or lumbar
  • Sacroiliac Joint injections.

The purpose of the spinal injection procedure can be either diagnostic or therapeutic.

GUIDELINES

Who is eligible for spinal injection therapies?

A client who has persistent spinal pain (see conditions below) as a result of his/her transport accident injuries is eligible for spinal injection therapies.

What conditions are spinal injection therapies appropriate for?

Spinal injection therapies are appropriate to diagnose or treat persistent spinal pain arising from nerve irritation or joint pain. Pain should have been present for longer than 3 months, should be VAS/NRS pain score 5 out of 10 or higher and have failed conservative therapy.

Who may perform spinal injection therapies?

Spinal injection therapies may be performed by any registered medical practitioner with sufficient training in spinal injection therapies. Training must include appropriate patient selection as well as technical expertise.

What can the TAC fund?

The TAC can fund the following spinal injection therapies:

• Lumbar epidural injection
• Lumbar facet joint injection
• Medial branch block for diagnostic purposes
• Cervical and thoracic facet joint injection for diagnostic purposes
• Sacro-iliac joint injection for diagnostic purposes.

The following procedures are considered non-established. If seeking one of these for a client, refer to the Non-Established, New or Emerging Treatments and Services policy.

• Hip joint or piriformis injections for treatment of spinal pain
• Epidural or nerve root sleeve injections of the cervical and thoracic regions
• Medial branch blocks for treatment of spinal pain
• Facet joint injections for treatment of pain in the cervical or thoracic regions
• Sacroiliac joint injections for treatment of spinal pain
• Injections of hyalase, chymopapain or any substance other than local anaesthetic and steroid.

Is prior written approval required?

To expedite payment of accounts and ensure the most appropriate services are provided to the client, the TAC encourages prior approval to be sought by the client's treating registered medical practitioner.

What information does the TAC require to approve a request for a spinal injection therapy?

The TAC requires the following information in order to approve a request for a spinal injection therapy:

• The site of the pain, likely diagnosis and relationship to the transport accident
• Baseline outcome measures
• The exact location of the injection (level and structure to be injected)
• The expected management plan if the spinal injection is successful (e.g. who will facilitate return to work) or is not successful (e.g. other treatment options).

Where the request is approved, a short report of the procedure together with the real-time outcome measures is expected to be forwarded to the TAC.

How long can the TAC fund spinal injection therapies for?

Diagnostic blocks may be repeated up to three times for one location in order to clearly diagnose pain generators through the use of placebo controlled blocks.

Lumbar epidural injections may be repeated up to three times within a few months, After the initial series if relief persists and is evident through clinically significant change on an outcome measure, functional improvement and/or reduction in healthcare use, future requests for lumbar epidurals will be considered. No more than three lumbar epidurals/year will be considered.

Lumbar facet joint injections may be repeated up to two times within a few months. After the initial series if relief persists and is evident through clinically significant change on an outcome measure, functional improvement and/or reduction in healthcare use, future requests for lumbar facet joint injections will be considered. No more than two lumbar facet joint injections/year will be considered.

How long before the TAC responds to a treating practitioner's request to perform a spinal injection therapy to a client?

The TAC will respond to the request within 10 working days of receiving the treating practitioner's written request, or if further information is required, within 3 working days of receiving the additional information. The TAC will write to the treating practitioner within 3 working days if further information is needed to determine liability.

What item numbers will the TAC fund for spinal injection therapies?

The TAC can fund spinal injections that are billed only in accordance with those items from the Medicare Benefits Schedule.

How are procedures administered to an in-patient in a public hospital billed to the TAC?

The cost of spinal injections administered in public hospitals by salaried hospital medical officers is covered in the Casemix billed to the TAC.

Spinal injection therapies administered in public hospitals by a medical practitioner or specialist with the right of private practice must be billed in accordance with those items from the Medicare Benefit Schedule. Payment for the treatment will be in accordance with the TAC Medical Practitioner fee schedule.

How are procedures received in a private hospital billed?

Spinal injection therapies administered in a private hospital by a medical practitioner or specialist with the right of private practice must be billed in accordance with those items from the Medicare Benefit Schedule. Payment for the treatment will be in accordance with the TAC Medical Practitioner fee schedule.

How are procedures that are received 'in rooms' billed?

Spinal injection therapies administered 'in rooms' by a medical practitioner or specialist must be billed in accordance with those items from the Medicare Benefit Schedule. Payment for the treatment will be in accordance with the TAC Medical Practitioner fee schedule.

Can the TAC fund services/treatment by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.

In relation to spinal injection therapies what will the TAC not fund?

The TAC will not fund:

• treatment or services for a person other than the injured client
• treatment or services where there is no proper clinical justification for this service
• treatment or services for a condition that existed before a transport accident or that is not a direct result of a transport accident
• spinal injection therapies where the area to be injected is not a major source of pain (e.g. VAS/NRS pain score less than 5 out of 10) or where pain has not been present for longer than 3 months, or where conservative treatment has not been tried.
• any repeat lumbar epidural or lumbar facet joint injection where there is lack of evidence of clinically significant change on an outcome measure, functional improvement and/or reduction in healthcare use
• repeat lumbar epidural injections more often than 3 times/year after the initial series
• repeat lumbar facet joint injections more often than 2 times/year after the initial series
• fees associated with non-attendance
• the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
• treatment or services subcontracted to a non-registered provider
• treatment or services provided outside the Commonwealth of Australia
• treatment or services provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

For further information see also the Evidence Review on the TAC website and the Practice Guidelines for Spinal Diagnostic and Treatment Procedures. International Spine Intervention Society. Edited by N Bogduk. 2004. Published by ISIS, California.