how are you all handling medicare SIJ with the new rules?

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DrMDAware said:
Steve, genuinely asking you and others with experience what procedures have you seen fizzled out or not up to snuff? I believe you. I'm looking for some historical perspective. TIA
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SI fusions. Anything going into a disc or to treat discogenic pain. PNS. PENS. Ankle blocks for neuropathy. Posterior spacers.
 
to add on:

discograms

intradiscal steroids
intradiscal ozone/antibiotics/hyaluronidase

racz catheter for adhesiolysis
cervical transforaminals

occipital stim
chemical nerve ablation (tho this is in one part being replaced by RFA and in the other part being limited by greedy pharma)
PNS as mentioned before

ITP (tho it seems to be making a 2nd comeback)

genetic testing for opioid resistance
 
Ducttape said:
to add on:

discograms

intradiscal steroids
intradiscal ozone/antibiotics/hyaluronidase

racz catheter for adhesiolysis
cervical transforaminals

occipital stim
chemical nerve ablation (tho this is in one part being replaced by RFA and in the other part being limited by greedy pharma)
PNS as mentioned before

ITP (tho it seems to be making a 2nd comeback)

genetic testing for opioid resistance
Click to expand...
agree with some of the list, in my previous practice, I had the opportunity to follow up on some implanted patients longitudinally, occipital stim works if the trial works, migration can be managed, ITP works for a certain group of patients, tolerance does occur after one year or so of using the pump, so does spinal cord stimulation.
 
SC Tian said:
agree with some of the list, in my previous practice, I had the opportunity to follow up on some implanted patients longitudinally, occipital stim works if the trial works, migration can be managed, ITP works for a certain group of patients, tolerance does occur after one year or so of using the pump, so does spinal cord stimulation.
Click to expand...
Agree on occipital stim. 90% of those patients did great with it long term.

Implant is tricky to avoid migration, but occipital stim works great, for properly selected patients.
 
stsa84 said:
I haven't changed anything yet. But I think I'll start documenting "diagnostic" blocks and just adding steroid. For one, it's the right thing to do from a patient care standpoint. Secondly, the prospect of trying to explain to patients the purpose of 2 diagnostic blocks before the therapeutic injection, for an freaking joint injection, is exhausting.

"So, you'll need have a needle in my SI joint?"
"Yes"
"But you're only going to inject a medicine that lasts a few hours?"
"Yes"
"And you're going to do this twice?"
"Yes"
"And then I'll finally be able to get the real medicine?"
"Yes"
"Can't you just put in the medicine that will last a longer time while you're in there the first time?'
"Well, you'd think..."
Click to expand...
The problem is, if you get an audit they will deny everything, including any facility/anesthesia/subsequent therapeutic injections
 
occipital stim.jpg
 
bedrock said:
Agree on occipital stim. 90% of those patients did great with it long term.

Implant is tricky to avoid migration, but occipital stim works great, for properly selected patients.
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My friend, here is the image showing how to anchor the occipital stim, the migration is not horrible after this.
 
Going back to the original reason I started this thread.......

I just checked, and both Cigna and BCBS have now adopted the same medicare rules. You must do two diagnostic SIJ (with two different kinds of local, even), before you can do a therapeutic SIJ injection, for both insurances.

Aetna still allows straight to therapeutic SIJ.....for now

I can't tell on UHC. Would be great if someone enlighted me regarding SIJ and UHC.
 
Options I see:
- do your SIJ injection as you always did, have all patients sign an ABN, if your $$ gets clawed back then go after patients directly for cash
- adopt new guidelines and do 2 extra stupid pointless procedures
- do your SIJ as you always did, just call the first two “diagnostic” in your notes
- “adopt” new guidelines, inject steroid with all of them but don’t document and don’t charge it
- tell patients your diagnosis, explain options of how you’d treat it and then explain BS insurance requirements, give them the cash option, insurance option, or live with it option
- take an employed position in an integrated health system where you don’t have to care
- take a job with the VA where you don’t have to care
-leave Pain Management

Some options are fraud. Some are unethical. Some are more ethical than what insurance companies are doing.

And I think the latter is exactly what Payors hope will happen. I get more convinced insurance lobbyists work with CMS and are actively trying to kill this profession.
 
Forgive me but where in the CMS guidelines does it say you have to do 2 diagnostic injections before you can do a therapeutic injection. The therapeutic SIJI requirement just states "The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain were taken pre-injection on the day of the diagnostic SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used,"
 
fyi, regarding occipital stim, my friend:

at best, 40% of leads in this retrospective analysis survived 1 year.

and this was only discussing explantation, not lead migration, as the researchers noted. also, retrospective study



this meta-analysis showed a 71% complication rate from the treatment.

Frontiers | Long term outcomes of occipital nerve stimulation

Background: Occipital nerve stimulation has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as ch...
www.frontiersin.org www.frontiersin.org

There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias.
Click to expand...

so 71% occipital stims will fail. any procedure that has a failure rate of 40 let alone 71% is difficult to justify.

do a bunch of them, my friend, and get back to us about how many stay in for more than a few months.
 
Medicare LCD:

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID
www.cms.gov www.cms.gov

B. Diagnostic SIJIs

Diagnostic SIJI is used to determine if the etiology of pain is from the SIJ complex.3

Diagnostic SIJI are considered reasonable and necessary for patients who meet ALL the following criteria:

    1. The patient must meet the above criteria for Covered Indications for SIJI, AND
    2. The SIJIs must be performed under computed tomography (CT) or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance,6 AND
    3. SIJI are not performed with other musculoskeletal injections in the lumbosacral spine, AND
    4. The documentation should show direct causal benefit from the SIJI and not from other musculoskeletal injections or treatments, AND
    5. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain must be taken pre-injection on the day of the SIJI, post-intervention on the day of the injection, and the days following the injection to substantiate and corroborate the pain scores consistent with the pain relief for the duration of the local anesthetic and/or steroid used.
Limitation: No more than 2 diagnostic joint sessions, unilateral or bilateral. To clarify, 2 unilateral sessions, if performed on 1 side at 1 session and on the opposite side at a different session, would meet the limitation of 2 diagnostic sessions.
Click to expand...
C. Therapeutic SIJI

Therapeutic SIJI will be considered medically reasonable and necessary for patients who meet ALL the following criteria:

    1. The patient must meet the above criteria of Covered Indications for SIJI, AND
    2. The diagnostic SIJI provided a minimum of 75% relief of primary (index) pain with the diagnostic SIJI (a positive diagnostic response is defined as ≥75% sustained and constant pain relief for the duration of the local anesthetic and ≥75% sustained and constant pain relief for the duration of the anti-inflammatory steroid) was measured by the SAME pain scale* at baseline. The measurements of pain were taken pre-injection on the day of the diagnostic SIJI, post-intervention on the day of the diagnostic injection, and the days following the diagnostic SIJI to substantiate and corroborate consistent pain relief for the duration of the local anesthetic and/or steroid used, AND
    3. Subsequent therapeutic SIJI are considered medically reasonable and necessary when the subsequent SIJI are provided at the same anatomic site as therapeutic SIJI, AND the therapeutic SIJI produced at least consistent 50% pain relief or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living (ADLs) for at least 3 months from the proximate therapeutic SIJI procedure and compared to baseline measurements for ADLS and painful movements or pain relief using the same pain scale* AND
    4. The SIJIs must be performed under CT or fluoroscopy image guidance with contrast, except ultrasound guidance may be considered reasonable and necessary when there is a documented contrast allergy or pregnancy, since the accuracy with ultrasound guidance is inferior to fluoroscopic guidance.6
Limitation: No more than 4 therapeutic SIJI sessions, unilateral or bilateral, will be reimbursed per rolling 12 months. To clarify, a therapeutic SIJI session if performed on 1 side first and then on the opposite side at a different session would qualify as 2 sessions for the limitation of 4 therapeutic SIJ sessions per rolling 12 months.
Click to expand...

you can do 2 diagnostic injections. each has to provide 75% reduction of pain for appropriate duration from local and from steroid.

i believe they allowed 2 diagnostic injections in case you did only 1 side at one session then suddenly needed to do the other side.

after that, 4 therapeutic injections that have to provide >50% reduction of pain or 50% improvement in activities of ADL for 3 months.


each block session counts as 1 injection session. so do bilat if there is any concern (otherwise doing right side one day then left side the other day counts as 2 sessions, and we only get 4 total)
 
Ducttape said:
Medicare LCD:

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID
www.cms.gov www.cms.gov




you can do 2 diagnostic injections. each has to provide 75% reduction of pain for appropriate duration from local and from steroid.

i believe they allowed 2 diagnostic injections in case you did only 1 side at one session then suddenly needed to do the other side.

after that, 4 therapeutic injections that have to provide >50% reduction of pain or 50% improvement in activities of ADL for 3 months.


each block session counts as 1 injection session. so do bilat if there is any concern (otherwise doing right side one day then left side the other day counts as 2 sessions, and we only get 4 total)
Click to expand...
This is the way I've interpreted it as well. I've changed my procedure template to label them as diagnostic, and to document pre/post pain schores, but still putting steroid in the injection. I might just start charging cash for them, though
 
bedrock said:
Going back to the original reason I started this thread.......

I just checked, and both Cigna and BCBS have now adopted the same medicare rules. You must do two diagnostic SIJ (with two different kinds of local, even), before you can do a therapeutic SIJ injection, for both insurances.

Aetna still allows straight to therapeutic SIJ.....for now

I can't tell on UHC. Would be great if someone enlighted me regarding SIJ and UHC.
Click to expand...
There is something called Interqual criteria for medical necessity that UH uses for SI
I cannot access the policy
-anyone out there experienced with the criteria?
 
GlowInTheDark said:
I think I got the “no steroid” until therapeutic injection from ASIPP releases, but I agree with GasChicago after re-reading the LCD.

This was the ASIPP “algorithm”
Click to expand...
The “algorithm” that counts is specific to the payer and they are not all in concordance
E.g. most plans requires 2 diagnostic blocks for facets either intraarticular of medial branch- United does not allow c2-3 level, whereas all others do
Intraarticular facet steroid injections are disallowed by most plans except for some BCBS or currently the UH medicare advantage policy
Degree of pain relief for a positive block can vary from 50%, 75%, 80% depending on the plan
Going forward getting a predetermination may be the wisest option
 
Ducttape said:
fyi, regarding occipital stim, my friend:

at best, 40% of leads in this retrospective analysis survived 1 year.

and this was only discussing explantation, not lead migration, as the researchers noted. also, retrospective study



this meta-analysis showed a 71% complication rate from the treatment.

Frontiers | Long term outcomes of occipital nerve stimulation

Background: Occipital nerve stimulation has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as ch...
www.frontiersin.org www.frontiersin.org



so 71% occipital stims will fail. any procedure that has a failure rate of 40 let alone 71% is difficult to justify.

do a bunch of them, my friend, and get back to us about how many stay in for more than a few months.
Click to expand...
Here are some debates about this:
There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias.
this is mainly about migration and associated treatment, not failure, the paper from Mayo Clinic dramatically changed the rate of migration almost to zero, I did only a few, they are pretty good so far. Ons achieves similar outcomes like scs if not better. Also i had one case implanted with paddle lead, there is no migration at all.please see below paper.
 
um...

you posted a retrospective "trial", based on cases from 2004 to 2011, and post it as a new innovative technique?

in fact, the article states that it was a study that looked retrospectively at "our current ONS surgical technique and to report clinical outcome variables in a retrospective fashion".

18 patients. duration to follow up 1 day to 81 months.

do you know the 2 patients that had the longest duration to follow up - did not have the tension loops placed? 81 months and 36 months, which kind of goes against recommending their technique. the longest the rest of the tension loop ones were 25 months.

the stats i quoted were from data during and after that time frame of your study - 2007 to 2017.
 
Ducttape said:
um...

you posted a retrospective "trial", based on cases from 2004 to 2011, and post it as a new innovative technique?

in fact, the article states that it was a study that looked retrospectively at "our current ONS surgical technique and to report clinical outcome variables in a retrospective fashion".

18 patients. duration to follow up 1 day to 81 months.

do you know the 2 patients that had the longest duration to follow up - did not have the tension loops placed? 81 months and 36 months, which kind of goes against recommending their technique. the longest the rest of the tension loop ones were 25 months.

the stats i quoted were from data during and after that time frame of your study - 2007 to 2017.
Click to expand...
Thanks for the careful review and interesting finding, is this retrospective paper is hard guideline for practice, definitely no. Can it help to reduce the migration for ons, i believe so. There are certain group of on patients they are desperate, ONS imo,play a role helping those people. This is also my clinical finding, in fact i have No failures in the past several years.
 
you need quality evidence to prove that something has changed.

you havent presented that.

patient desperation is not an indication to perform a specific treatment. quality evidence is.


this is not to say that occipital stim does not have its place in pain management or that we should not offer it.


it is to say that lead migration is a significant complication affecting possibly up to 71% and why i do not believe it is "up to snuff" and has "fizzled out" in its application.
 
This will be my last message on this topic, when I talked about desperate, you know what that means, neuromodulation is the last resort of pain management, and they failed most of the conservative management.
There are so many topics of pain management that lack qualified evidence, CLO for a cervical epidural, tf versus interlaminar ep, peripheral nerve stims, and even different types of scs, we very often utilize common practice rationale you may not agree with as no high-level evidence exists.
If migration is a big issue, can we do something to improve it? This paper answered some questions even though you pointed out some problems, NEJM RCTs for kypho can be challenged as well. If you want further evidence, a large trial is needed. In my practice this works for me, if this double-anchor approach failed, I would put a paddle lead in, I don't think it is an abandoned procedure.
 
SC Tian said:
This will be my last message on this topic, when I talked about desperate, you know what that means, neuromodulation is the last resort of pain management, and they failed most of the conservative management.
There are so many topics of pain management that lack qualified evidence, CLO for a cervical epidural, tf versus interlaminar ep, peripheral nerve stims, and even different types of scs, we very often utilize common practice rationale you may not agree with as no high-level evidence exists.
If migration is a big issue, can we do something to improve it? This paper answered some questions even though you pointed out some problems, NEJM RCTs for kypho can be challenged as well. If you want further evidence, a large trial is needed. In my practice this works for me, if this double-anchor approach failed, I would put a paddle lead in, I don't think it is an abandoned procedure.
Click to expand...
agree with you. I have done 8 occipital stims and non have migrated. Just because other docs can;t do this correctly, doesn't mean that it should never been done for patients that need.
 
desperate patients dont mean we need to do desperate treatments.

most treatments we do have some basis for benefit (CLO, ESI, SCS). occipital stim does have data that supports its use. unfortunately, the problem with stim remains lead migration, limiting its use (and limiting insurance coverage). hence the reason it is "not up to snuff".

i think it is much more appropriate to try occipital stim than, say, intradiscal injection of traumeel...
 
Ducttape said:
Medicare LCD:

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID
www.cms.gov www.cms.gov




you can do 2 diagnostic injections. each has to provide 75% reduction of pain for appropriate duration from local and from steroid.

i believe they allowed 2 diagnostic injections in case you did only 1 side at one session then suddenly needed to do the other side.

after that, 4 therapeutic injections that have to provide >50% reduction of pain or 50% improvement in activities of ADL for 3 months.


each block session counts as 1 injection session. so do bilat if there is any concern (otherwise doing right side one day then left side the other day counts as 2 sessions, and we only get 4 total)
Click to expand...
Based on this I have been just documenting the KX-50 or RT/LT if it’s a SIJ-first timer and still using steroid since that segment you posted talks about steroid in the diagnostic injections. I think utilizing the diagnostic inj with LA only is just an option, but if you add steroid then you can’t do another for 3 months. I’m think *AT THIS POINT* they are trying to eliminate the people billing multiple SIJ inj in a row, like my former partner who would do it with steroid and if 30%+ relief or whatever arbitrary percentage he would do it again 3 weeks out thinking maybe you just needed another inj for additive effect, then maybe a third time a month later of that one helped 50%, then 3 mos later repeat etc. I think they are trying to clean up THAT variety of mess now and then will go after us harder later.
 
With plans that require prior auths like Medi-cal( California Medicaid) or Medicare advantage has anyone had instances when prior auth was given but then they tried to claw back due to lack of documentation per Medicare guideline?
 
strike5858 said:
With plans that require prior auths like Medi-cal( California Medicaid) or Medicare advantage has anyone had instances when prior auth was given but then they tried to claw back due to lack of documentation per Medicare guideline?
Click to expand...
Not at this point but it is likely on their to-do list
 
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