Back Pain - Invasive Procedures (CPB 0016, reviewed 2026-02-11)

IMMEDIATE ACTION REQUIRED - By February 18, 2026: (1) Billing team must implement prior authorization verification for all back pain invasive procedures in billing software, referencing CPB 0016. (2) Update encounter forms and clinical templates to document required medical necessity criteria: facet injections require 6+ weeks conservative treatment, 80% pain relief threshold, and radiofrequency consideration; trigger point injections require 3+ months symptoms and comprehensive pain program; sacroiliac injections require 70% pain relief on initial injection and 3 of 5 physical exam maneuvers. (3) Providers must document that only ONE invasive modality will be used at a time per policy. (4) Implement billing rules to deny/reject claims for: ultrasound-guided facet or trigger point injections (marked experimental), diagnostic facet injections without radiofrequency consideration, trigger point injections repeated more frequently than every 7 days initially or every 2 months therapeutically, sacroiliac injections repeated more frequently than every 7 days, or sacroiliac injections without 70% pain reduction threshold met. (5) For sacroiliac injections, limit to 2 initial diagnostic/therapeutic injections, then up to 4 additional per 12 months if 70% threshold achieved. (6) For trigger point injections, limit to 4 sets maximum; reject additional sets if no clinical response. (7) Obtain and maintain precertification per CPT code search tool as required. Consequences: Claims submitted without meeting these criteria will be denied by Aetna, resulting in revenue loss and patient balance issues.