All injxns now denied?

[SommeRiver]

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Can someone explain why my facet injxn is denied?

 

[callmeanesthesia]

Can someone explain why my facet injxn is denied?

It’s in their policy - they don’t consider facet steroid injections medically necessary, only diagnostic injections (MBBs, or diagnostic facet injections).

“Facet joint injections (intra-articular and medial branch blocks) containing corticosteroids are considered therapeutic injections. Aetna considers diagnostic facet joint injections not medically necessary where radiofrequency facet neurolysis is not being considered.“

Also, looks like 2 MBBs are required but they will only authorize one at a time.

 

[jsaul]

they are saying they will cover only diagnostic facet blocks or radiofrequency facet procedures but no steroid into facet joints

 

[SSdoc33]

i dont do many intra-articular facets, but this is a garbage policy. there are certainly a sliver of patients who are better suited to intra-articular than MBB for a variety of reasons

 

[drusso]

Can someone explain why my facet injxn is denied?

Just issue an ABN of non-coverage to the patient and a cash price quote.

 

[lobelsteve]

Or perform what is covered.

 

[SommeRiver]

So...I can do a therapeutic CSI right?

This CPT code is by definition meant to infer a therapeutic benefit. Why can't I do it?

 

[drusso]

Or perform what is covered.

No one wants insurance companies meddling in medical decisions and the doctor-patient relationship.

 

[SommeRiver]

I don't care one way or the other if I do a facet injxn or an MBB/RFA...I just don't understand the rationale here...

 

[drusso]

I don't care one way or the other if I do a facet injxn or an MBB/RFA...I just don't understand the rationale here...

There is none. It is an arbitrary decision made by people with no real content knowledge in pain/spine domain. They simply want to erect barriers to care.

 

[deleted993114]

Can someone explain why my facet injxn is denied?

The key there is Aetna. Aetna would not approve water if you were on fire. They would want you to go through alternative methods of extinguishment first.

 

[SommeRiver]

I usually do MBB/RFA instead of facet injxns but I try to avoid the potential for multifidus changes in younger patients and instead do facet injxns.

So when these 35 yo patients come in with facet disease and MRI evidence of facet arthropathy and they've failed conservative Tx I have to ablate them instead of doing a joint injxn?

I don't get it.

This is stupid.

 

[Ducttape]

the evidence that they quote suggest that there is no good data to suggest long term benefit from facet joint steroid injections.

at this point in time, I save the facet joint injection with steroids to the No Fault crowd.

as a side note, you can do a facet joint injection with local only as a diagnostic injection in prelude to a RFA. so it is not the injection itself - it is the use of medications and the diagnostic vs. therapeutic intent that is why it is denied.



you can appeal, but you will have to find some study to suggest that there is long term benefit from the FJI with steroids. given that RFA has some data to suggest that there is long term benefit, its unlikely that they will buy your argument that the FJI with steroids is a better long term option, as it wont last as long as a successful RFA.

 

[lobelsteve]

There is good evidence that there is no benefit to IA facet injections. There is good evidence for the dbl dx block paradigm resulting in RFA.

 

[drusso]

There is good evidence that there is no benefit to IA facet injections. There is good evidence for the dbl dx block paradigm resulting in RFA.

Just make sure you never confuse "coverage" for "care." And, just because a third party pays for something, it doesn't mean it works.

 

[DOctorJay]

I know most SIS instruction is to avoid FJI but lobelsteve, do you avoid them completely or use them occasionally in situations as mentioned above by sommeriver?

 

[lobelsteve]

I know most SIS instruction is to avoid FJI but lobelsteve, do you avoid them completely or use them occasionally in situations as mentioned above by sommeriver?

Only for cysts.

 

[SSdoc33]

i still dont like doing an RF on someone in their 30's. im with sommeriver on this one.

that being said, it is an unusual situation for a younger person to have facet pain in the absence of trauma

 

[drusso]

Only for cysts.

Radiofrequency Ablation Treatment: What You Need To Know

Radiofrequency ablation (RFA) disrupts nerve signals to manage chronic pain, but its effectiveness may vary by condition and individual response.

regenexx.com

 

[SommeRiver]

that being said, it is an unusual situation for a younger person to have facet pain in the absence of trauma

Yeah, but it still happens. Again, I'm probably 90% of the time doing medial nerve interventions but the denial is still pretty ridiculous IMO.

 

[10KHertz]

Remember it’s not Aetna or any insurance company, per se, that’s denying your MBB to RFA auth. It’s the third party administrators, like Magellan, AIM, Etc. They are doing the dirty work. Illegally and unethically IMO. Yet state insurance commissioner’s do jack...

BCBC in my state has the same policy in terms of no MBb steroids and dual blocks.

Just do what what the policy tells you to do . they have the kryptonite now...

 

[pmrmd]

Just put the 1-2cc of dex in the syringe but don’t document it or bill it.


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[cbest]

Remember it’s not Aetna or any insurance company, per se, that’s denying your MBB to RFA auth. It’s the third party administrators, like Magellan, AIM, Etc. They are doing the dirty work. Illegally and unethically IMO. Yet state insurance commissioner’s do jack...

BCBC in my state has the same policy in terms of no MBb steroids and dual blocks.

Just do what what the policy tells you to do . they have the kryptonite now...

Sorry, why are people putting steroid in their MBBs and are you NOT doing two MBBs prior to RFA?


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[promethius]

It’s in their policy - they don’t consider facet steroid injections medically necessary, only diagnostic injections (MBBs, or diagnostic facet injections).

“Facet joint injections (intra-articular and medial branch blocks) containing corticosteroids are considered therapeutic injections. Aetna considers diagnostic facet joint injections not medically necessary where radiofrequency facet neurolysis is not being considered.“

Also, looks like 2 MBBs are required but they will only authorize one at a time.

I agree with this assessment. I recently got approved by Aetna to perform lumbosacral facet joint injections on a patient. After the procedure was performed, the claim was submitted. When I got the electronic remittance advice back, I noticed that Aetna paid the claim for the injections and the contrast, but did not pay for the steroid, as they deemed the use of steroid for these injections to be "experimental" and "investigational."

Maybe someone on here can help me with a related denial for a procedure I recently performed. I submitted a claim for CPT code 20551 and paired it with diagnosis code M79.10, but the procedure got denied because "ICD code on the claim [was] not supported by billed procedure." I called the insurance company and spoke to a representative. All the representative could tell me was that they follow CMS guidelines. Do you know which diagnosis codes can be paired with CPT code 20551? Better yet, where can I find this information? I rather not have to dig through thousands of pages of policy manuals if I do not have to.

 

[DOctorJay]

I agree with this assessment. I recently got approved by Aetna to perform lumbosacral facet joint injections on a patient. After the procedure was performed, the claim was submitted. When I got the electronic remittance advice back, I noticed that Aetna paid the claim for the injections and the contrast, but did not pay for the steroid, as they deemed the use of steroid for these injections to be "experimental" and "investigational."

Maybe someone on here can help me with a related denial for a procedure I recently performed. I submitted a claim for CPT code 20551 and paired it with diagnosis code M79.10, but the procedure got denied because "ICD code on the claim [was] not supported by billed procedure." I called the insurance company and spoke to a representative. All the representative could tell me was that they follow CMS guidelines. Do you know which diagnosis codes can be paired with CPT code 20551? Better yet, where can I find this information? I rather not have to dig through thousands of pages of policy manuals if I do not have to.

Gotta love medicine. In what other industry when you call to ask someone for help do they refuse to tell you the answer?


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[Ducttape]

M79.18

 

[Extralong]

Gotta love medicine. In what other industry when you call to ask someone for help do they refuse to tell you the answer?


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In the help line for ATT or Comcast.

 

[promethius]

M79.18

Hey just wanted to follow-up regarding the pairing of this ICD10 code with CPT code 20551. The procedure got reimbursed. Thank you!