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Workers comp treatment rules on epidural steroid injections may tighten

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Warnings by the U.S. Food and Drug Administration could lead state workers compensation systems and payers to tighten treatment guidelines for epidural steroid injections.

Epidural steroid injections are used to treat radicular pain, which occurs when a nerve root becomes irritated and pain radiates to the extremities, experts say, adding that it's often caused by a herniated disc.

However, some say the injections can be costly and overutilized in the treatment of injured workers. And in rare circumstances, they can have serious side effects or be fatal.

An advisory panel to the FDA on Nov. 25 voted on whether there are certain clinical situations that warrant adding a contraindication, or strong warning, to the label of such injections. The majority approved, in a 15-7 vote with one abstention, an FDA spokesman said.

The FDA has yet to take further action, but said in April of this year that epidural steroid injections could have rare but serious side effects, such as blindness, stroke, paralysis or death. Additionally, 14 people associated with New England Compounding Center Inc. were charged last week in connection with the 2012 fungal meningitis outbreak in which 64 people died from contaminated doses of a medication used for epidural steroid injections.

Despite warnings, epidural steroid injections are still recommended by most of the evidence-based resources used in workers comp, said Dr. Jacob Lazarovic, Sunrise, Florida-based chief medical officer for third-party administrator Broadspire Services Inc.

But having updated treatment guidelines could save money, observers say, as the injections tend to be overutilized and cost anywhere from a couple of hundred dollars to a couple of thousand dollars, depending on whether they are given in an inpatient or outpatient procedure.

Many states either have their own treatment guidelines that outline when and how many epidural steroid injections are appropriate for injured workers, or they rely on the Official Disability Guidelines or American College of Occupational and Environmental Medicine guidelines.

“There are several differences between all of these guidelines, but they all have basic similarities in terms of defining when and how frequently” an epidural steroid injection should be used,” Dr. Lazarovic said. For the most part, they say injections become an option if the injured worker's radicular pain hasn't improved after four to six weeks of conservative treatments and that, when used alone, they offer no long-term functional benefit, he added.

Alternatively, Colorado's treatment guidelines say epidural steroid injections might make sense within the first two to three weeks after an injury or the onset of pain, said Dr. Kathryn Mueller, medical director for the Colorado Division of Workers' Compensation, president of the American College of Occupational and Environmental Medicine, and a professor at the University of Colorado Denver's Anschutz Medical Campus. This is to facilitate an injured worker's ability to partake in conservative treatments, she added.

“The idea of our practice guidelines is if you fit within the protocol, then you do not need prior authorization,” Dr. Mueller said. “The purpose of this is to decrease wasted administrative expenses ... In our state, you may not use any other guideline.”

In states that don't disallow prior authorization, payers like Broadspire can utilize their own guidelines when deciding whether to authorize or reimburse epidural steroid injections.

“We look for the symptoms of radiculopathy to be documented by the treating physician, objectively,” Dr. Lazarovic said. “We look to see whether there have been attempts at conservative therapy that have failed ... We require six weeks of conservative therapy before we will consider authorizing an epidural steroid.”

Images from MRIs or CT scans are also studied to make sure there is some nerve root compression before authorizing an injection, Dr. Lazarovic said, adding that only one injection is authorized at a time, with a maximum of four injections permitted in one year.

Historically, the injections were ordered in a series of three, “but the vast majority of evidence-based medicine agrees that approving three all in one shot does not make sense,” said Mark Pew, senior vice president of product development at Prium, a Duluth, Georgia-based medical management company.

A best practice in workers comp, which is used in New York and by some payers, is to recommend scheduling each injection separately and then seeing if a second or third one is appropriate based on the injured worker's response to the first one, Mr. Pew said.

Unlike pharmacy benefit managers that put out drug trend reports, payers don't typically disclose results of utilization reviews, which makes it difficult to know exactly how many epidural steroid injections are given to injured workers each year, Mr. Pew said.

However, the Centers for Medicare and Medicaid Services alone paid for nearly 9 million epidural steroid injections in 2013, according to news reports.

Whatever the number, the percentage of people with radicular pain who are appropriate candidates for epidural steroid injections “is very small compared to the population that we've been putting injections in,” Dr. Mueller said.