New Medicare LCD for epidural treatment under proposal

[Doctodd]

i will usually repeat in 2 weeks if acute radic. Commercial insurance will follow but their patient population is different.

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[spondy14]

Anyone know if this is already in effect or when the projected start date is?

 

[emd123]

Sorry, I’m a little late to the party here. Is Medicare limiting to 4 total esi’s (whole body) or 4 for neck and 4 for lumbar, each?

The wording is different in a couple of places.

 

[Agast]

Sorry, I’m a little late to the party here. Is Medicare limiting to 4 total esi’s (whole body) or 4 for neck and 4 for lumbar, each?

The wording is different in a couple of places.

Per spine region so it’s actually more generous than I expected

 

[Laryngospasm]

Start saving your money boys and girls..

 

[painfree23]

“12. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.”

So if a patient gets a year of relief, we can’t repeat the ESI 12 months later ?

 

[deleted875186]

“12. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.”

So if a patient gets a year of relief, we can’t repeat the ESI 12 months later ?

I wish they came out and said this about opioids, but I guess those are just less expensive ….

 

[emd123]

“12. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.”

So if a patient gets a year of relief, we can’t repeat the ESI 12 months later ?

A few lines down they say it's okay if the patient isn't a surgical candidate, doesn't want surgery, you try other treatment options, also, etc. So, like 95% of my patients.

 

[ateria radicularis magna]

A few lines down they say it's okay if the patient isn't a surgical candidate, doesn't want surgery, you try other treatment options, also, etc. So, like 95% of my patients.

I think you also have to document specific improvement of function (odi or whatever), and >50 % improvement in vas for at least 3 months right ?

 

[ctts]

What are your thoughts on patients who get both cervical and lumbar ESIs?

I generally avoid doing both in the same session, in case of complication, could be hard to know which is the source. But for some patients, if they have good relief with cervical ESI and lumbar ESI in separate sessions, rather then having them come in more often, I sometimes do both in one session.

I have a patient in this situation, and I told her today that we cannot do both in the same session, so she wants to come in every 1.5 months to alternate between cervical and lumbar ESI. I would prefer maybe every 2 months, but that would mean 4 months between injections for a particular region rather than 3 and it might not be acceptable for her.

 

[RoloTomassi]

What are your thoughts on patients who get both cervical and lumbar ESIs?

I generally avoid doing both in the same session, in case of complication, could be hard to know which is the source. But for some patients, if they have good relief with cervical ESI and lumbar ESI in separate sessions, rather then having them come in more often, I sometimes do both in one session.

I have a patient in this situation, and I told her today that we cannot do both in the same session, so she wants to come in every 1.5 months to alternate between cervical and lumbar ESI. I would prefer maybe every 2 months, but that would mean 4 months between injections for a particular region rather than 3 and it might not be acceptable for her.

Do you always get paid 100% for both? 59 modifier? The risk of not getting paid fully for one turns me off to this.

I don't like the idea of every 1.5 months because hormones are constantly cycling 3 weeks off, 3 weeks normal. Rather do 2 injections close but not same day.

 

[painfree23]

Do you always get paid 100% for both? 59 modifier? The risk of not getting paid fully for one turns me off to this.

I don't like the idea of every 1.5 months because hormones are constantly cycling 3 weeks off, 3 weeks normal. Rather do 2 injections close but not same day.

Why not same day? I tell them it’s too much steroid for a day

 

[RoloTomassi]

Why not same day? I tell them it’s too much steroid for a day

Full reimbursement for both is the main concern, but that too

 

[Drd105]

Anyone know if this is already in effect or when the projected start date is?

This is my question- does anyone know if it is official yet?
Also- does this probably mean if I do a right L5 I could not do the left L5 two months later?

 

[pmrmd]

Oh it’s in effect now. They even retro’d the effective date.

 

[Drd105]

View attachment 347867Oh it’s in effect now. They even retro’d the effective date.

“If a patient fails to respond well to the initial ESI, repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate….”

Limited to 4 in 12 mos

I am happy with that so far

Can someone help me clarify the “covered indications” section- I think the commas are poorly placed- does it look like you MUST use either lumbar radicular pain OR neurogenic claudication? I often do b/l for discogenic pain but it looks like that is not allowed…?

 

[Ferrismonk]

“If a patient fails to respond well to the initial ESI, repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate….”

Limited to 4 in 12 mos

I am happy with that so far

Can someone help me clarify the “covered indications” section- I think the commas are poorly placed- does it look like you MUST use either lumbar radicular pain OR neurogenic claudication? I often do b/l for discogenic pain but it looks like that is not allowed…?

That's because ESI doesn't work for discogenic pain.