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Coverage Guideline

Subject: Document #: Status: Percutaneous Facet Neurolysis for Chronic Back Pain SURG.00066 Current Effective Date: Revised Last Review Date: 10/22/2008 08/28/2008

Description/Scope

Chronic cervical and lumbosacral spinal pain that is identified as being facet in origin may be treated by RF neurolysis when intermittent anesthetic injections no longer provide extended pain relief. Other techniques have been proposed to ablate facet sources of pain. These include pulsed radiofrequency (PRF), lasers and chemical neurolysis for cervical/lumbosacral facet pain. Note: Please see the following related document(s) for additional information: · SURG.00090 Treatments for Trigeminal Neuralgia

Position Statement

Medically Necessary: Radiofrequency (RF) neurolysis for cervical and lumbosacral facet pain is considered medically necessary when all of the following criteria are met: No prior spinal fusion surgery in the vertebral level being treated; Pain is not radicular; Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; Pain has failed to respond to three (3) months of conservative management as documented in the medical record which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy and a home exercise program; A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or injection under fluoroscopic guidance into the facet joint has resulted in at least a 50% reduction in pain; A minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine). Investigational and Not Medically Necessary: Radiofrequency neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain for all uses that do not meet the criteria identified as medically necessary listed above, including but not limited to treatment of thoracic facet or sacroiliac (SI) joint pain; Chemical neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain; Pulsed radiofrequency neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain;

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 1 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

SURG.00066

Radiofrequency neurolysis for sacroiliac (SI) joint pain is considered investigational and not medically necessary; Laser neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.

Rationale

Radiofrequency (RF) facet neurolysis The clinical studies of radiofrequency facet neurolysis for chronic spinal pain have methodological limitations that can affect interpretation of the data. The preponderance of the evidence is derived from small randomized controlled trials, and prospective uncontrolled studies, case series, and retrospective chart analyses. Outcomes from prospective uncontrolled and retrospective studies on RF facet neurolysis have demonstrated moderate to strong short-term reduction in pain symptoms in some patients (Savitz, 1991; North, 1994; Tzaan, 2000; Pevsner, 2003; Ferrante, 2001; Gevargez, 2002). Evidence from randomized, controlled trials demonstrated a significant placebo effect, and conflicting results were obtained from trials investigating RF facet neurolysis for cervical pain syndrome (van Kleef, 1996; Slappendel, 1997) and low back pain (Gallagher, 1994; Leclaire, 2001). While there is some evidence that RF facet neurolysis provides pain relief in selected patients with chronic spine pain, many patients do not experience complete pain relief, and the durability of the effects remains unclear. Success rate depends on careful selection of patients including documented reduction in pain in response to temporary block with local anesthetic of the facet nerve or injection under fluoroscopic guidance into the facet joint. In addition, the technique was most successful in patients without a prior history of back surgery. There is consensus among pain management specialists that pain may reoccur and that re-treatment may be required. However, re-treatment should not occur in the same location of the spine unless a minimum time period of 6 months has elapsed since prior treatment. The incidence of thoracic facet pain is significantly lower than cervical/lumbrosacral facet pain and there is a paucity of evidence supporting RF facet neurolysis for thoracic facet pain, therefore, conclusions cannot be drawn as to the clinical efficacy of this application. RF neurolysis in areas other than facet joints, namely the sacroiliac (SI) joint, have been proposed, but the published literature does not demonstrate its clinical efficacy. Currently, there is a randomized, single blind, placebo-controlled, crossover clinical trial in progress that is studying the use of RF for sacroiliac joint pain. Pulsed radiofrequency (PRF) facet neurolysis Pulsed radiofrequency (PRF) facet neurolysis has been investigated as a potentially less harmful alternative to RF facet neurolysis in the management of facet joint pain, however the published literature regarding pulsed radiofrequency facet neurolysis for chronic pain syndromes currently is insufficient to assess the efficacy of this procedure and permit scientific conclusions. Mikeladze and colleagues (2003) reported on the treatment of lumbar or cervical spine facet joint pathology by application of PRF facet neurolysis to the medial branches of the dorsal rami at the appropriate spinal level. This retrospective study included 114 patients at a pain management clinic with clinical signs of facet joint involvement and a favorable response to a diagnostic medial branch block using local anesthetic. Mean duration of pain was 7.52 ± 5.26 years. The result was regarded as successful if pain reduction was more than 50% on a visual analog scale and the duration of effect was more than 1.5 months. Of 114 patients who had a positive response to

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 2 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

SURG.00066

diagnostic block, 46 patients did not respond favorably to PRF facet neurolysis application (pain reduction less than 50%). In 68 patients, the procedure was successful and lasted on average 3.93 ± 1.86 months. Eighteen patients had the procedure repeated with the same duration of pain relief that was achieved initially. The authors concluded that the application of PRF facet neurolysis to medial branches of the dorsal rami in patients with chronic facet joint arthropathy provided temporary pain relief in 68 of 118 patients. However, the authors note that, because of the relatively short duration of effect and the higher success rate with longer duration of RF facet neurolysis, PRF facet neurolysis appears less effective than the established entity. Chemical facet neurolysis The use of chemical facet injections such as phenol, alcohol and hypertonic saline has been proposed as an option for pain relief. However, there is a lack of published data to support the safety and efficacy of this technique. Laser facet neurolysis Laser facet neurolysis has been proposed for facet or sacroiliac pain. One small case series was found. Iwatsuki et al (2007) reported treatment of facet syndrome by laser neurolysis in 21 study participants including five who had undergone previous spinal surgery. One year after laser denervation, 17 patients experienced pain reduction of at least 70%. Of the five patients who had previously undergone spinal surgery, four did not have a successful outcome from laser denervation at 1-year follow-up. There was no control group in this study. The published literature is insufficient to support the efficacy of laser neurolysis for facet or sacroiliac joint pain.

Background/Overview

Treatment of chronic cervical and lumbosacral pain is complex due to the subjective nature and the origin of the pain itself. Chronic cervical, lumbar and sacral pain is frequently attributed to disorders of the facet joint. Neck pain related to whiplash injury is also thought to be related to the cervical zygapophyseal facet joint. These pain impulses can be interrupted by blocking the nerve to the facet joint with an anesthetic injection (facet block), coagulating the nerve with heat using a radiofrequency wave (radiofrequency neurolysis) preventing the neural transmission of pain. The nerve to the facet joint is sometimes referred to as the "medial branch" and therefore facet nerve block is also referred to as "medial branch" block. Typically, facet joint blocks are performed as a part of a workup for neck or low back pain. Pain relief following a precise injection of local anesthetic confirms the facet joint as the source of pain. Before radiofrequency facet neurolytic procedures, it is imperative that the source of pain is identified and placement of the probe/needle is confirmed. Radiofrequency facet neurolysis is a procedure in which sensory afferent nerve fibers are selectively destroyed with heat produced by radio waves delivered through an electrode. Treatment objectives are to eliminate pain, reduce the likelihood of recurrence and prolong the time to recurrence by selectively destroying pain fibers without inducing excessive sensory loss, motor dysfunction, or other complications. RF facet neurolysis also has the potential risk of neuritis. Histological studies have revealed indiscriminate destruction of both small and large fibers following the RF treatment. For this reason, pulsed radiofrequency (PRF) facet neurolysis neurolysis has been investigated as a treatment for chronic pain syndromes. PRF facet neurolysis is thought to be a non destructive alternative to standard RF in that it applies RF energy with a pulsed time cycle that delivers short bursts of RF current instead of a continuous RF flow. By pulsing the electrical current, the needle remains relatively cool (up to 42 degrees celsius compared to temperatures of 60-69 degrees celsius with continuous RF) so that the tissue cools slightly between each burst, reducing the risk of destroying nearby tissue and preventing any long-term damage to the nerve. It is postulated that this disrupts the transmission of impulses across small unmyelinated fibers without destroying them while larger fibers remain protected by the myelin sheath.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 3 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

SURG.00066

Laser neurolysis has been studied for use in facet pain. To date, only one small study has been published.

Definitions

Ablation: the removal or destruction of a body part or tissue or its function. Ablation may be performed by surgery, hormones, drugs, radiofrequency, heat or other methods Facet: interlocking bones on the vertebrae which allow the spine to flex while maintaining its stability Neurolysis: the destruction of nerves or nerve tissue by heat, cutting or by chemical injection Radiofrequency: an invasive procedure that involves heating tissue in order to destroy it

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met: CPT 64622 64623 64626 64627 Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level (when specified as radiofrequency facet neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (when specified as radiofrequency facet neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level (when specified as radiofrequency facet neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (when specified as radiofrequency facet neurolysis)

ICD-9 Procedure 03.96 ICD-9 Diagnosis

Percutaneous denervation of facet (when specified as radiofrequency facet neurolysis)

All diagnoses When services are Investigational and Not Medically Necessary: For the procedure codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary. When services are also Investigational and Not Medically Necessary: When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary CPT

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 4 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

64622 64623 64626 64627

SURG.00066

No specific code for pulsed radiofrequency or laser neurolysis Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level (when specified as chemical, pulsed radiofrequency or laser neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (when specified as chemical, pulsed radiofrequency or laser neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level (when specified as chemical, pulsed radiofrequency or laser neurolysis) Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (when specified as chemical, pulsed radiofrequency or laser neurolysis)

ICD-9 Procedure 03.96

Percutaneous denervation of facet (when specified as chemical, pulsed radiofrequency or laser neurolysis)

ICD-9 Diagnosis All diagnoses

References

Peer Reviewed Publications: 1. Ahadian FM. Pulsed radiofrequency neurotomy: advances in pain medicine. Current Pain and Headache Reports; 2004; 8 (1): 34-40. 2. Cohen SP, Raja SN. Pathogenesis, Diagnosis and Treatment of Lumbar Zygapophysial (Facet) Joint Pain. Anesthesiology 2007; 5(106):591­614 3. Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analog. 2005; 101(5):1440-1453. 4. Ferrante FM, King LF, Roche EA, et al. Radiofrequency sacroiliac joint denervation for sacroiliac syndrome. Reg Anesth Pain Med. 2001; 26(2):137-142. 5. Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroiliac joint: anatomy, physiology and clinical significance. Pain Physician. 2006; 9(1):61-67. 6. Gallagher J, et al. Radiofrequency facet joint denervation in the treatment of low back pain: A prospective controlled double-blind study to assess its efficacy. Clin J Pain. 1994; 7:193-198. 7. Gevargez A, Groenemeyer D, Schirp S, Braun M. CT-guided percutaneous radiofrequency denervation of the sacroiliac joint. Eur Radiol. 2002; 12(6):1360-1365. 8. Geurts, J W, et al. Efficacy of radiofrequency procedures for the treatment of spinal pain: a systematic review of randomized clinical trials. Reg Anesth Pain Med. 2001; 26:394-400. 9. Iwatsuki K, Yoshimine T, Awazu K. Alternative denervation using laser irradiation in lumbar facet syndrome. Lasers Surg Med. 2007; 39(3):225-229. 10. Jerosch J, Castro WH. Percutaneous facet coagulation. Neurosurgery Clinics of N America 1996; 7(1):119-130. 11. Kornick C, Kramarich SS, Lamer TJ, et al. Complications of lumbar facet radiofrequency denervation. Spine. 2004; 29(12):1352-1354. 12. Leclaire R, Fortin L, Lambert R, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo controlled clinical trial to assess efficacy. Spine. 2001; 26(13):1411-1417. 13. Lord SM, Barnsley L, Wallis BJ., et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996; 335:1721-1726.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 5 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

SURG.00066

14. McKenzie-Brown AM, Shah RV, Sehgal N, Everett CR. A systematic review of sacroiliac joint interventions. Pain Physician. 2005; 8(1):115-125. 15. Mikeladze G, Espinal R, Finnegan R, et al. Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain. Spine J. 2003; 3(5):360-362. 16. North RB, Han M, Zahurak M, Kidd DH. Radiofrequency lumbar facet denervation: analysis of prognostic factors. Pain. 1994: 57:77-83. 17. Pevsner Y, Shabat S, Catz A, et al. The role of radiofrequency in the treatment of mechanical pain of spinal origin. Eur Spine J. 2003; 28:28. 18. Pino CA, Hoeft MA, Hofsess C, Rathmell JP. Morphologic analysis of bipolar radiofrequency lesions: implications for treatment of the sacroiliac joint. Reg Anesth Pain Med. 2005; 30(4):335-338. 19. Savitz MH. Percutaneous radiofrequency rhizotomy of the lumbar facets; ten years' experience. The Mount Sinai Journal of Medicine 1991; 58(2):177-178. 20. Slappendel R, Crul BJ, Braak GJ, et al. The efficacy of radiofrequency lesioning of the cervical spinal dorsal root ganglion in a double blinded randomized study: no difference between 40ºC and 67ºC treatments. Pain. 1997; 73:159-163. 21. Slipman, et al. A critical review of the evidence for the use of zygapophysial injections and radiofrequency denervation in the treatment of low back pain. Spine J. 2003; 3:310-316. 22. Stovner, et al. Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study. Cephalalgia 2004; 24:821-830. 23. Tzaan WC, Tasker RR. Percutaneous radiofrequency facet rhizotomy ­ experience with 118 procedures and reappraisal of its value. Can J Neurol Sci. 2000;27(2):125-130. 24. Vallejo R, Benyamin RM, Kramer J, et al. Pulsed radiofrequency denervation for the treatment of sacroiliac joint syndrome. Pain Med. 2006; 7(5):429-434. 25. van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999; 24(18):1937-1942. 26. van Kleef M, Liem L, Lousberg R, et al. Radiofrequency lesion adjacent to the dorsal root ganglion for cervicobrachial pain: a prospective double blind randomized study. Neurosurgery. 1996; 38(6):1127-1132. 27. van Zundert J, Brabant S, Van de Kelft E, et al. Pulsed Radiofrequency treatment of the gasserian ganglion in patients with idiopathic trigeminal neuralgia. Pain. 2003; 104(3):449-452. Government Agency, Medical Society, and Other Authoritative Publications: 1. American Society of Anesthesiologists, Inc. Practice guidelines for chronic pain management: a report by the American society of Anesthesiologists task force on pain management, chronic pain section. Anesthesiology. 1997; 86(4):995-1004. Available at: http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-19970400000032.htm;jsessionid=FrpJzVhh2c8Bc5vkGjJ43QbB3dchjvjDHnT21sQyZv7QGjfG78x3!-1455700262!949856145!8091!-1 Accessed on July 1, 2008. 2. Hayes Inc. Hayes Medical Technology Directory. Radiofrequency Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; March 2007. Search updated April 17, 2008. 3. Hayes Inc. Hayes Medical Technology Directory. Radiofrequency Ablation for Cervical and Thoracic Back Pain. Lansdale, PA: Hayes, Inc.; March 2007. Search updated April 14, 2008. 4. National Institutes of Health (NIH) A Placebo-Controlled Study Assessing Lateral Branch Radiofrequency Denervation for Sacroiliac (SI) Joint Pain. NLM Identifier: NCT00373724. Last updated on May 7, 2008. Available at: http://www.clinicaltrials.gov/ct/show/NCT00373724 . Accessed on July 1, 2008. 5. Niemisto L, Kalso E, Malmivaara A, et al. Radiofrequency denervation for neck and back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2003; 28(16):18771888.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 6 of 7

Coverage Guideline

Percutaneous Facet Neurolysis for Chronic Back Pain

SURG.00066

6. National Institute of Neurological Disorders and Stroke (NINDS) Website. Low back pain fact sheet. Available at: http://www.ninds.nih.gov/disorders/backpain/backpain.htm Accessed on July 1, 2008.

Index

Facet Joint Nerves Chemical Neurolysis Laser Neurolysis Pulsed Radiofrequency Radiofrequency Neurolysis Sacroiliac Joint Zygapophyseal Joint Pain

Document History

Status Revised Date 08/28/2008 Action Medical Policy & Technology Assessment Committee (MPTAC) review. Title changed to Percutaneous Facet Neurolysis for Chronic Back Pain. Chemical facet neurolysis added to investigational and not medically necessary section. PRF for trigeminal neuralgia criteria and information deleted and addressed in SURG.00090. Investigational and not medically necessary criteria clarified. Rationale, background and references updated. MPTAC review. Laser neurolysis added to investigational and not medically necessary criteria. Rationale, background and references updated. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting. MPTAC review. Rationale, coding and references updated. MPTAC review. Document revised to combine MED.00071 Pulsed Radiofrequency (PRF) Treatment for Chronic Pain Syndromes with this document; radiofrequency (RF) of the sacroiliac (SI) joint addressed. References updated. MPTAC review. Revised to include sacroiliac joint. MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. Last Review Date 07/27/2004 Document Number SURG.00052 Title Chronic Spine Pain Treatments/Procedures (Minimally Invasive) Percutaneous Radiofrequency Neurolytic Destruction of Facet Joint Nerves

Revised

05/15/2008 02/21/2008

Reviewed Revised

05/17/2007 12/07/2006

Revised Revised

06/08/2006 07/14/2005

Pre-Merger Organizations Anthem, Inc.

WellPoint Health Networks, Inc.

12/02/2004

3.07.05

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Coverage Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Coverage Guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. © CPT Only ­ American Medical Association Page 7 of 7

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