SIJ RFA denial

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drpainfree

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Applied for PA of SIJ RFA for patient with BC in California. The PA was denied for "the treatment is investigational".

We applied for 64635 (L5) and 64640 (posterior rami lateral branch). We were not planning to use Simplicity.

Anyone has any documents to support the procedure and received PA approval?
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I think it was a new policy starting in July that RFA of the SI joint would be considered investigational for BCBS. My insurance girl showed me the letter.

drpainfree said:
Applied for PA of SIJ RFA for patient with BC in California. The PA was denied for "the treatment is investigational".

We applied for 64635 (L5) and 64640 (posterior rami lateral branch). We were not planning to use Simplicity.

Anyone has any documents to support the procedure and received PA approval?
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this is national policy or just local BCBS in CA?

so what are we supposed to do now with these patients? She clearly benefited from SIJ blocks.

I hate to go to SCS at this point without trying something less invasive first.
 
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You could always fuse the sij..I'm sure those pricks will cover that :wtf:
 
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I'm in Texas.

I encourage everyone who does a recorded peer to peer for insurance approval to ask why <big name insurance> would fuel the opioid epidemic by denying procedures that are a standard part of interventional pain.

drpainfree said:
this is national policy or just local BCBS in CA?

so what are we supposed to do now with these patients? She clearly benefited from SIJ blocks.

I hate to go to SCS at this point without trying something less invasive first.
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I was just at a cooled workshop over the weekend and the presenter (from Tx) said he billed it as a regular lumbar RF, 721.3 with 64635 + 64636 x 2. I specifically said he was billing the wrong thing. He didn't seem to care
 
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clubdeac said:
I was just at a cooled workshop over the weekend and the presenter (from Tx) said he billed it as a regular lumbar RF, 721.3 with 64635 + 64636 x 2. I specifically said he was billing the wrong thing. He didn't seem to care
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I have always been disappointed with kimberly-clark's marketing. I have several family members that work for the company but not in the halyard division. They are teaching you to commit fraud and should be called out on it. Halyard would make it seem that as long as you buy their products everything is okay.
 
so it's a no-go with BCBS for SIJ RFA? no need to peer-to-peer?
 
Could you post a link to their rules in your state?

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Evicore, formerly Carecorenational.com. Page 28 of Musculoskeletal program section

III. Sacroiliac denervation or neurolysis.
By any method is considered investigational at this time.


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In Louisiana, Evicore does not insure anyone directly. They do Utilization Review for Wellcare

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I was speaking to the OP

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I just plan on bending over and taking some S1-3 rf, as long as I get paid for L5S1 facet.


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Taus are you doing L4MB and L5DR or just L5DR plus S1-3?


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so taus, you are saying you'd do L4, L5 MNB RFA, AND S1-S3 DR RFA, but be content with getting paid for L4 and L5 MNB RFA only?
 
drpainfree said:
so taus, you are saying you'd do L4, L5 MNB RFA, AND S1-S3 DR RFA, but be content with getting paid for L4 and L5 MNB RFA only?
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No need to do S3. Put 4 needle in at L4 mb, L5 dorsal primary ramus, S1 and S2 lateral branches and bill for two level RF? May be walking the line but heh, gotta do something
 
drpainfree said:
so taus, you are saying you'd do L4, L5 MNB RFA, AND S1-S3 DR RFA, but be content with getting paid for L4 and L5 MNB RFA only?
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Not happy about it at all, but as a worst case scenario it's better than getting paid nothing or not being able to do the procedure when that coverage situation occasionally arises.


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clubdeac said:
No need to do S3. Put 4 needle in at L4 mb, L5 dorsal primary ramus, S1 and S2 lateral branches and bill for two level RF? May be walking the line but heh, gotta do something
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This is what I do
 
I will see if L5 and S1 MBB help with some of the pain, then do L5, S1, S2, S3, S4 RFA - and have patient pay for cost of needle and time for the S2-S4 RFA. Facility gets paid from the L5 and S1 RFA. dictate it separate as two separate procedures to keep it clean.
 
axm397 said:
I will see if L5 and S1 MBB help with some of the pain, then do L5, S1, S2, S3, S4 RFA - and have patient pay for cost of needle and time for the S2-S4 RFA. Facility gets paid from the L5 and S1 RFA. dictate it separate as two separate procedures to keep it clean.
Click to expand...

thanks for the tip. I might consider to offer the patient the option.
 
Ducttape said:
Drpainfree, I'm not trying to be mean, but could you charge $1500 self pay to this lady, like you charge for the 3 level TFs?




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yes, ducttape, no offense taken. She did ask me if I would do it for my cash price. I hesitated and gave her my honest opinions: in my experience only 50% patients would get long lasting benefit from SIJ RFA. She decided to wait.

Like I said, I would not want to a cash procedure unless I have 90%+ success rate. Wouldn't sleep well.

and one correction, I charge $1500 flat fee for whatever procedure I do, single-level or IESI with RACz catheter.
 
That is excessive. I charge Medicare rates for cash pay patients.
 
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