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Pain Management Societies Urge CMS to Cover ESIs for Chronic Pain

The discussion over using epidural steroid injections to manage pain continues as AAPM and six other specialty organizations request Medicare recipient coverage.

with Kim Mauer, MD and Bridger Bach, MD

The American Academy of Pain Medicine (AAPM) joined six other pain specialty societies in urging CMS to include coverage of epidural steroid injections (ESIs) for the management of chronic pain in Medicare recipients. Their request was submitted via a letter to the Medicare Administrative Contract Medical Directors in February 2021.

The signatories wrote that the benefits of ESIs should be available to Medicare patients because of the “significant relief of radicular neck and back pain, improved quality of life, with restoration of function and return to work, as well as decreased utilization of other healthcare resources” that this therapy provides. Acknowledging questions regarding the safety of ESI procedures, the signatories noted, “When epidural injections are performed in a disciplined, responsible manner, they achieve outcomes that are clinically, socially, and economically worthwhile.”1 The letter included a variety of published research to support their position including how ESIs can improve function and quality of life for patients.

The issue has not been without controversy, however. In 2014, the FDA issued a warning about ESIs, pointing to serious, though rare, complications, such as “loss of vision, stroke, paralysis, and death.”2  At that time, AAPM, along with the American Society of Anesthesiologists, wrote to the FDA disagreeing with the designation, pointing out the safety record of the procedure when the appropriate formulation of steroids is used and the procedure is performed with proper technique.

Since then, questions have remained regarding for which patients and for what pathologies the treatment should be used, as well as its safest formulations and techniques.

The professional societies did acknowledge in their letter that, “There is no doubt that ESIs are not the panacea for all spinal conditions. There are conditions best treated conservatively and others best treated surgically ….”1

“Imaging has improved and now we can do more precise injections in less time,” to manage chronic pain, said Dr. Kim Mauer. (Image: iStock)

ESIs: Patient Selection is Key

Kim Mauer, MD, Medical Director of the Comprehensive Pain Clinic at Oregon Health and Science University, agrees that ESI treatment has come a long way in recent years. “Imaging has improved and now we can do more precise injections in less time,” she told PPM.

Selecting the appropriate patients for this therapy is crucial, however, and there are many nuances to the process.

Bridger Bach, MD, clinical fellow in pain medicine at the Vanderbilt University Medical Center in Tennessee, spoke about candidacy for ESIs. He explained, for instance, that patients who have progressive, incurable conditions – such as spinal stenosis – with significant comorbidities – such as renal disease or heart disease – would be poor candidates for long-term treatment with NSAIDs. This same group of patients may also be poor candidates for opioid therapy because of liver or pulmonary disease or past opioid use disorder. As a result, ESIs may be the best treatment choice for them.

In addition, older patients are often on multiple medications, such as benzodiazepines or muscle relaxants, that put them at risk for respiratory events. According to Dr. Bach, “This might be a good group for epidural steroid injections as a good addition to their analgesic regime because it helps them achieve their goals of pain reduction and functionality while being a relatively safe type of treatment for them.”

Another advantage of using ESI in this population is that the treatment provides patients with more options and a greater control over the choice of therapeutic approach. “It’s important to understand the patient’s goals and wishes,” said Bach. “Do they wish to avoid certain types of treatments, therapies, or surgery? Those are things you can take into account.”

ESIs can also be used as a short-term support for other therapies, he noted. “Sometimes you can do an injection just to help them get through a course of physical therapy.”

Next Steps in Interventional Pain Medicine

AAPM closed their letter by stating, “The MPW [Multisociety Pain Workgroup] societies would welcome the opportunity to again work with the Medicare Administrative Contractors to revise the coverage criteria included in the LCDs [local coverage determinations] to ensure appropriate access to epidural injections for Medicare patients.”

Meanwhile, clinicians should be aware that the decision to recommend ESI can be a tricky one. For those in primary care, Dr. Mauer recommends consulting a pain specialist when in doubt.

Last updated on: March 11, 2021
Continue Reading:
Epidural Steroid Injections: Are the Risks Worth the Benefits?
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