Medicare facet denials

[so55b]

I think we only have to document the pain score between MBBs and RFA but not the functional disability scale. The functional disability scale must be documented only before the first MBB according to the guideline below.
Am I right?

*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment.

A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment)


A second diagnostic facet procedure is considered medically necessary to confirm validity of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure. Clinical circumstances that necessitate an exception to the two-week duration may be considered on an individual basis and must be clearly documented in the medical record. For the first diagnostic facet joint procedure: For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the patient must meet the criteria outlined under indications for facet joint interventions. a. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet ALL the following criteria: b. i. The patient meets the criteria for the first diagnostic procedure; AND After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used)

Initial thermal RFA: After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used) AND i. Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months 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;

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[MedZeppelin]

Here is a ridiculous situation I am running in to......A patient presents for a REPEAT lumbar RFA which has successfully improved pain and function at least 50% for 6 months. She has received repeat RFA every 6-12 months as needed. Now, Patient is DENIED RFA because the original diagnostic blocks completed 3 years prior had pain improvement scores of only 70% with first and second MBB! Regardless of the fact the patient has had almost complete pain improvement with successive RFA over the years. Now patient is required to go back and have repeat MBB to confirm benefit.
Talk about waste of medical resources!
Any others have similar issue?

 

[MitchLevi]

Two Dx MBB is dumb.

Over the course of your career, that adds up to a substantial difference in radiation exposure to you and your staff.

It should be one Dx MBB prior to RFA IMO.

I have done many absurd P2P over this procedure. I recently had one where the "peer" refused to give me her first name, and when I pressed her for her name for documentation purposes she flatly rejected because she "is in no way required to give my name to you."

 

[cowboydoc]

Two Dx MBB is dumb.

Over the course of your career, that adds up to a substantial difference in radiation exposure to you and your staff.

It should be one Dx MBB prior to RFA IMO.

I have done many absurd P2P over this procedure. I recently had one where the "peer" refused to give me her first name, and when I pressed her for her name for documentation purposes she flatly rejected because she "is in no way required to give my name to you."

NP that was going by “Doctor (first name)” that got flustered?

 

[oneforfighting]

This is such a mess. I had my first wave of denials recently. Apparently Medicare has 10 days and will take the full 10 days to notify us of a decision. I have only had denials thus far. For reference, I'm HOPD. Trying to adjust my notes to try to reflect the game they are playing.

What do you do for the patient who has persistent extremity pain due to stenosis even after ESI? Just had her MBBs rejected because of this. Do I need have them fib and say they no longer experience any pain in their legs? Any ideas?

 

[Dr. Ice]

This is such a mess. I had my first wave of denials recently. Apparently Medicare has 10 days and will take the full 10 days to notify us of a decision. I have only had denials thus far. For reference, I'm HOPD. Trying to adjust my notes to try to reflect the game they are playing.

What do you do for the patient who has persistent extremity pain due to stenosis even after ESI? Just had her MBBs rejected because of this. Do I need have them fib and say they no longer experience any pain in their legs? Any ideas?

Maybe they need surgery. Maybe the algorithmic approach to esi then mbb then maybe rfa is not right…

 

[callmeanesthesia]

This is such a mess. I had my first wave of denials recently. Apparently Medicare has 10 days and will take the full 10 days to notify us of a decision. I have only had denials thus far. For reference, I'm HOPD. Trying to adjust my notes to try to reflect the game they are playing.

What do you do for the patient who has persistent extremity pain due to stenosis even after ESI? Just had her MBBs rejected because of this. Do I need have them fib and say they no longer experience any pain in their legs? Any ideas?

Well, IIRC the specific language is that patient has no “untreated radiculopathy.” You did treat it with your epidural…

 

[bedrock]

This is such a mess. I had my first wave of denials recently. Apparently Medicare has 10 days and will take the full 10 days to notify us of a decision. I have only had denials thus far. For reference, I'm HOPD. Trying to adjust my notes to try to reflect the game they are playing.

What do you do for the patient who has persistent extremity pain due to stenosis even after ESI? Just had her MBBs rejected because of this. Do I need have them fib and say they no longer experience any pain in their legs? Any ideas?

Maybe they need surgery. Maybe the algorithmic approach to esi then mbb then maybe rfa is not right…

If mild intermittent paresthesia, you are right. If more than that, then I agree with Dr. ice in that maybe you need to send these patients for surgery.

If mild intermittent paresthesia only, then yes I would lie because the *****s who came up with these rules do not understand the realities of providing pain care to patients.

I use the CPT code frequently, lumbar spondylosis without radiculopathy M47.817 Should be hard to deny that code.

 

[oneforfighting]

Maybe they need surgery. Maybe the algorithmic approach to esi then mbb then maybe rfa is not right…

Yes but what if they don’t want surgery? Or if they are old and recovering from a stroke and have several other co-morbidities that make them high risk? This is my patient. She wants to do whatever she can to avoid surgery. Pain in leg is much improved after ESI. But not entirely resolved. Now most of pain is axial and concordant with severe facet arthropathy seen on xray/MRI. Do I just give up on her?

 

[oneforfighting]

Well, IIRC the specific language is that patient has no “untreated radiculopathy.” You did treat it with your epidural…

This is what I would argue. But my staff call and spoke to FOUR different reps at CMS or wherever and they all either told us to resubmit all documentation (what would that do?) or told us to refer to the LCD. There’s no peer to peer option. What the heck? No choice now except to lie on all new and returning MBBs. Your pain is/was 100% axial, preprocedure pain 8/10 and post procedure pain 0/10 with duration of relief 6 hours concordant with 0.5% bupivacaine. Pain in the leg referred from facets? Never heard it. Numbness in legs from stenosis? Too risky to document.

 

[MitchLevi]

This is what I would argue. But my staff call and spoke to FOUR different reps at CMS or wherever and they all either told us to resubmit all documentation (what would that do?) or told us to refer to the LCD. There’s no peer to peer option. What the heck? No choice now except to lie on all new and returning MBBs. Your pain is/was 100% axial, preprocedure pain 8/10 and post procedure pain 0/10 with duration of relief 6 hours concordant with 0.5% bupivacaine. Pain in the leg referred from facets? Never heard it. Numbness in legs from stenosis? Too risky to document.

Facets commonly refer to leg

 

[Ducttape]

you can resubmit for the denied RFA by stating that the last 2 procedures provided clinically meaningful benefit, and completely not discuss the MBB.

see so55B's post.

Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months 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;

 

[callmeanesthesia]

I think the answer is to keep your notes as simple and templated as possible. Sure, maybe they still have some tingling in the leg after the epidural, but your note just says “patient notes >50% improvement in their radiculopathy pain after epidural steroid injection with improvement in ADLs. Their primary complaint now is axial low back pain. Make a template that’s a checklist of the Medicare criteria.
Patient meets the following medical necessity criteria: blah blah blah.

 

[myrandom2003]

Maybe they need surgery. Maybe the algorithmic approach to esi then mbb then maybe rfa is not right…

This algorithm is more because of insurance denials of ESI after Facets, or so I thought.

 

[oneforfighting]

I think the answer is to keep your notes as simple and templated as possible. Sure, maybe they still have some tingling in the leg after the epidural, but your note just says “patient notes >50% improvement in their radiculopathy pain after epidural steroid injection with improvement in ADLs. Their primary complaint now is axial low back pain. Make a template that’s a checklist of the Medicare criteria.
Patient meets the following medical necessity criteria: blah blah blah.

I’m going to try this and resubmit

 

[Dr. Ice]

This algorithm is more because of insurance denials of ESI after Facets, or so I thought.

Point is there shouldn’t be an algorithm at all regardless of insurance denials

 

[Crybaby]

Medicare help:

The denials have been a killer

For a specific patient with mbb x 2 truly with good relief
He is >80 so spine is a degenerative wreck

In note I documented date and VAS pain relief 10/10-1/10
50% improvement in oswestry
and detailed previously failed therapy

My denial reasons were listed-

1) improvement not documented
2) did not specifically say pain present for 3 months- this has been treated for years by different physicinas
3) failure to respond to conservative care
4) absence of untreated radiculopathy / neurogenic claudication- he had radic and had laminectomy 2 years ago?
5) assessment of radiology detailing non facet pain generators
6) other

Anyone else having issues?

 

[soccrwz]

Medicare help:

The denials have been a killer

For a specific patient with mbb x 2 truly with good relief
He is >80 so spine is a degenerative wreck

In note I documented date and VAS pain relief 10/10-1/10
50% improvement in oswestry
and detailed previously failed therapy

My denial reasons were listed-

1) improvement not documented
2) did not specifically say pain present for 3 months- this has been treated for years by different physicinas
3) failure to respond to conservative care
4) absence of untreated radiculopathy / neurogenic claudication- he had radic and had laminectomy 2 years ago?
5) assessment of radiology detailing non facet pain generators
6) other

Anyone else having issues?

is this MA; recent PT or lack there of seems to be a common reason nowadays for denial

 

[buddababa]

Medicare help:

The denials have been a killer

For a specific patient with mbb x 2 truly with good relief
He is >80 so spine is a degenerative wreck

In note I documented date and VAS pain relief 10/10-1/10
50% improvement in oswestry
and detailed previously failed therapy

My denial reasons were listed-

1) improvement not documented
2) did not specifically say pain present for 3 months- this has been treated for years by different physicinas
3) failure to respond to conservative care
4) absence of untreated radiculopathy / neurogenic claudication- he had radic and had laminectomy 2 years ago?
5) assessment of radiology detailing non facet pain generators
6) other

Anyone else having issues?

Same. Absurd

 

[Ducttape]

does your smartphrase for auth include lines to cover these bases?

for example:

"Patient has had pain for >3 months, and has been doing home based exercise program and conservative therapy including lifestyle changes with no improvement...

"the diagnostic and differential median branch blocks provided >80% reduction of pain for the appropriate duration of the local anesthetic and the patient stated functionality improved with *** "

 

[Crybaby]

does your smartphrase for auth include lines to cover these bases?

for example:

"Patient has had pain for >3 months, and has been doing home based exercise program and conservative therapy including lifestyle changes with no improvement...

"the diagnostic and differential median branch blocks provided >80% reduction of pain for the appropriate duration of the local anesthetic and the patient stated functionality improved with *** "

I do not have smart phrases, but this is my new generic HPI for rfa template .

I recommend radiofrequency ablation.
To summarize
Patient has chronic pain lasting over 6 months which has disrupted quality of life and ability to stay active to meet the bare minimum of AMA activity recommendations.
Plain radiographs show obvious facet arthritis which correlates with patient's specific pain.
Patient has failed PT/HEP/activity modification.
Patient has demonstrated greater than 80% relief using pain VAS
Specifically, MBB #1 Pre VAS 10/10 post VAS 2/10
MBB #2 Pre VAS 10/10 post VAS 2/10
Other causes of lumbar pain effectively ruled out with gold standard of mbb for diagnosis.
Patient noted improvement in ADLs and higher level activities following the two diagnostic medial branch blocks targeting the affected facet joints, during the duration of the local anesthetic. OLBPQ showed significant improvement, greater than 50% from baseline score. Patient is a good candidate for radiofrequency ablation and is hopeful to proceed.

 

[lobelsteve]

I do not have smart phrases, but this is my new generic HPI for rfa template .

I recommend radiofrequency ablation.
To summarize
Patient has chronic pain lasting over 6 months which has disrupted quality of life and ability to stay active to meet the bare minimum of AMA activity recommendations.
Plain radiographs show obvious facet arthritis which correlates with patient's specific pain.
Patient has failed PT/HEP/activity modification.
Patient has demonstrated greater than 80% relief using pain VAS
Specifically, MBB #1 Pre VAS 10/10 post VAS 2/10
MBB #2 Pre VAS 10/10 post VAS 2/10
Other causes of lumbar pain effectively ruled out with gold standard of mbb for diagnosis.
Patient noted improvement in ADLs and higher level activities following the two diagnostic medial branch blocks targeting the affected facet joints, during the duration of the local anesthetic. OLBPQ showed significant improvement, greater than 50% from baseline score. Patient is a good candidate for radiofrequency ablation and is hopeful to proceed.

Need dates of PT or copy of HEP and results.

 

[nynydoc]

Need dates of PT or copy of HEP and results.

This has been a major cause of denial: dates of PT and HEP/ Results

 

[gaschicago]

is this for procedures done at ASC/hospital or in office?

 

[jsaul]

It's only for facet procedures done in hospitals.. not asc or office

 

[Asclepius186]

Templates matching LCD guidelines are a must.

Wish EMR had a function for random date generator for 6 week time period between 0 and 6 months ago for dates of PT.

But seriously asking for dates of PT is absurd.

 

[jsaul]

Have they asked for submission of documentation of said PT. Like notes from PT

 

[nynydoc]

is this for procedures done at ASC/hospital or in office?

So yes, it is more of an issue with hospital.

With that being said I had this conversation with management and the denial is based on the physicians note and documentation of what is required. Point being that if it is denied for the hospital, it will likely be denied for any other place of service with the caveat that it isn’t a pre-auth issue but a potential audit issue in the future in the office setting. At least that is how it was conveyed to me, that regardless everything needs to be documented up to lcd guidelines

 

[Ducttape]

if i remember correctly, your management is wrong, and the change in guidelines was to have these procedures done in office or ASC and not HOPD.

 

[Crybaby]

Here is the form that Novitas has used to deny- hope it's helpful for someone