Updates on LCDs

Updated Information on the Nationwide LCD Policy for Epidural Procedures for Pain Management

CGS has released its final policy for epidural steroid injections for pain management has been released. This will be effective 12/5/2021. Please check your individual MACs.

There are some changes as per the request of ASIPP and other societies in reference to the definition of inclusion criteria:

This now includes radicular pain, severe degenerative disc disease, and post laminectomy syndrome.

  • An objective pain scale or functional assessment must be performed at baseline and repeated at each follow-up for assessment of response.
  • Pain duration of at least four (4) weeks, and the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4) weeks of noninvasive conservative care.
  • Only one spinal region may be treated per session.

Diagnostic codes do not include disc displacement and disc degeneration. All in all, the policy is extremely difficult to live with, not only for diagnostic coding, but for limitation of procedures limited to 4 per year for all regions combined.

This is a nationwide policy, but we are seeing some discrepancies with the he various policies. Some have a limit of four (4) epidurals per region and others are stating a limit of four (4) for all regions. We will clarify this soon, but it appears to be four (4) per region.

However, it also says that after the first treatment, a patient must have 3 months of ≥ 50% relief. If that is not achieved, a second procedure may be performed after 14 days using a different approach after appropriate documentation, which is very difficult.

Other issues also include in reference to documentation of at least 2 fluoroscopic views, pre and post pain levels each time.

LCDs released are:

GGS

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39015&ver=9&bc=0

NGS:

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39036&ver=8&bc=0

Palmetto

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38994&ver=7&bc=0

First Coast

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33906&ver=51&&sortBy=type&bc=2

Novitas

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36920&ver=68&&sortBy=type&bc=

WPS

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39054&ver=3&&sortBy=type&bc=2