Interventional pain management techniques in general, facet joint interventions, and epidural interventions in particular, have been in the news for the past year. There have been 2 reports from the Office of Inspector General (OIG) covering the frequency of therapeutic facet joint injections and another report from Noridian with only 49% of the claims meeting appropriateness criteria.
Based on the Cures Act to provide uniformity and transparency, new local coverage determinations (LCDs) have been established. Consequently, a multijurisdictional expert committee had hearings on potential coverages on the future for facet joint interventions in May 2020 and for epidural interventions in February 2021.
Following the multijurisdictional policy meeting, a proposed LCD was released. Numerous comments have been made, and a final LCD was released last night. Overall, it restricts therapeutic facet joint interventions in some jurisdictions and providers better coverage in other jurisdictions. This is a well-researched policy without affecting patient care and at the same time, avoiding excessive usage, leading to investigations if LCD is followed.
Meredith Loveless, MD, CGS Medical Director, and Leslie Stevens, Medical Director of First Coast and Novitas Solutions Medical Affairs, will be speaking at our annual meeting about preparation of the LCDs and facet joint interventions as a case study. The final LCD, which will be a national one, will be as follows:
- Two (2) diagnostic blocks with positive results of 80% or more with 2 weeks apart between the procedures.
- Therapeutic facet joint procedures: After the diagnosis of facet joint pain with two (2) diagnostic blocks, subsequent therapeutic facet joint procedures may be provided with at least 50% pain relief or at least 3 months from the prior therapeutic procedure, or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.
- However, it is required that the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device). These indications may not be limited. They may depend on each patient and shared-decision makin
- Diagnostic Intraarticular facet joint injections may be performed prior to therapeutic intraarticular injections.
- Frequency limitations is for each covered spinal region. No more than 4 therapeutic facet joint sessions will be reimbursed for rolling 12 months.
- Facet joint denervation: There is no significant change in this. Limited to two (2) radiofrequency sessions per region with documentation of 50% improvement of pain or function for 6 months.
There have been significant arguments and guidance from various organizations. To look over the full policy and the comments click on the following links:
To pull up your specific Medicare Administrator’s policy click on Medicare Coverage Database. You can search by choosing “Final LCDs Alphabetical Index.”
We would like to thank the Medicare Directors for their hard work. We also thank the membership of American Society of Interventional Pain Physicians (ASIPP), and other societies which provided input. More importantly, we would like to express our appreciation for the patients’ support. Finally, we thank Members of the Congress providing input into decision- making to maintain appropriate access to patient care.