Medial branch block with steroid - RFA denied

Discussion in 'Pain Medicine' started by giddyup, 05.20.14.

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  1. giddyup

    giddyup ASA Member 7+ Year Member

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    So I have a patient who had lumbar medial branch blocks done with near 100% relief immediately post procedure. I put a small amount of steroid (10mg kenalog) in the block to give her some longer lasting relief until we got her RFA approved. Spoke to a doc at her insurance company and they approved RFA. Performed RFA. Now a new doc calling from insurance company stating the RFA is now NOT approved because I used steroid and that is a therapeutic block not a diagnostic block, regardless of the immediate relief she received post procedure. So, now I'm not going to get reimbursed for the RFAs I already performed. Anyone else have this issue? I have never had this problem before. He is requesting literature to "support my practice as it is not standard of care". Anyone have any ideas?

    Thanks in advance.
     
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  3. SSdoc33

    SSdoc33 7+ Year Member

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    #1 -- obviously, the RFA shouldnt have been approved, then not approved. they are playing games.
    #2 -- there is no such thing as a "therapeutic" medial branch block, despite what manchikanti says
    #3 -- never put any steroid into a MBB, as it is a strictly diagnostic procedure. if you are looking for a therapeutic response, do an intra-articular Z-joint injection
     
  4. bedrock

    bedrock Member 10+ Year Member

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    What he said. It's not worth the hassle. Also it makes the diagnostic block less accurate, (per Paul Dreyfuss, who is more of an expert on MBB and RF than the rest of).

    Fight this one, but don't use steroid in your MBB in the future.
     
  5. pmrmd

    pmrmd SDN Lifetime Donor Lifetime Donor 7+ Year Member

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    Agree with SSdoc on #1 but not on #3. Write a letter stating that the steroid makes no difference overall. Quite often I have had long term benefit with dex spread over the capsule and nerve. It only helps the insurance company that if the response is prolonged, the RF can be avoided. Medicare specifically states you can do this, so I would argue the CMS angle.
     
  6. SSdoc33

    SSdoc33 7+ Year Member

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    putting in steroid increases the volume and decreases the specificity.

    no such thing as a therapeutic MBB. doesnt matter that "sometimes patients get long term relief". i see this sometimes with marcaine alone
     
  7. ziggyziggy

    ziggyziggy 5+ Year Member

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    I used to do MBB + Facet steroid injection in the past with no problems. Basically, two injection at two different sites at a same level but not using any LA in facet steroid injection.
     
  8. emd123

    emd123 5+ Year Member

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    Explain, please.
     
  9. SSdoc33

    SSdoc33 7+ Year Member

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    Maybe everybody should re-read the Bogduk stuff instead of just 'winging it'. Rf is the only thing we do well, but only if we do it right.

    Lax is a clown, and his papers a few years ago are simply not believable. Who gets 2 weeks out of an MBB with or without steroid?

    ISIS, not ASIPP
     
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  10. emd123

    emd123 5+ Year Member

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    I don't put steroids in my MBBs either. That's because I want the purest block possible, and I don't want the steroid effect to cloud the results and interpretation of the response.

    But the reason I asked you to explain, is because the concept of adding a steroid to a nerve block to prolong the effect of the block and to have some therapeutic effect, is not a new or controversial one. I don't think it's needed during an MBB, and agree that it increases your rate of false positive MBB, but I don't think the concept of a "therapeutic nerve block" with some steroid added is necessarily "blasphemy" or imaginary.
     
  11. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    If you are going to use steroid as part of your block, don't document it.
     
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  12. SSdoc33

    SSdoc33 7+ Year Member

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    i would say that it is fraud if you dont. even though i dont like getting into legalese with ampaphb, if you dont document it, i would think you cant bill for the steroid, and you are liable for SOEMTHING if there is a complication. allergic reaction to the steroid or preservative? something seems off about doing that.
     
  13. SSdoc33

    SSdoc33 7+ Year Member

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    i knew that you were leading me down that pathway with your open-ended question.

    i recognize the fact that steroids prolong the affect of the nerve block. so you are going from 5 hours of pain relief with bupi to what? 10 hours with bupi + steroid. WAY TO GO!!!!

    you are more likely putting some steroid peri-articular and getting some mild pain relief from structures including, but not limited to the z-joint. you are messing up the diagnostic value of the injection. is it the worst thing in the world? no. but to add steroid to a MBB for the express reason to give "longer lasting" pain relief is bogus.
     
  14. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    Fraud is a legal term of art docs would be wel advised to not use. That being said, it's like underbilling - yes, technically the OIG can go after you, but show me a case where they actually have.

    As for an allergic reaction to steroid, I find this counter-intuitive. If your adrenals are pumping the endogenous variety into your system diurnally, how can you be allergic to the stuff?
     
  15. emd123

    emd123 5+ Year Member

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    To the additives/preservatives. Rare, but can happen.
     
  16. SSdoc33

    SSdoc33 7+ Year Member

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    gdamn it. i knew i shouldnt have started this.

    i was unaware that your adrenals also pumped out benzyl alcohol or whatever the preservative is.
     
  17. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    use preservative free stuff...

    fyi, while you might think there is no such thing as a therapeutic MBB, clearly there are multiple clinics out there that do believe so. review some of the patient information on multiple pain clinic sites, from brigham and womans pain clinic to UC San Diego, as a couple of quick examples, have steroids listed as a possible part of the medial branch blocks.

    additionally, this study like this one: http://www.ncbi.nlm.nih.gov/pubmed/23177113
    specifically include steroid as part of the procedure, suggesting that there are researchers that specifically view the steroid component being beneficial.

    can you quote studies that specifically refute long term benefit from steroids?

    (i dont use steroids for my MBB, if at least because the LCD prohibits it, but because i do believe that steroids alter a diagnostic block. playing devils advocate).
     
  18. lord_jeebus

    lord_jeebus 和魂洋才 SDN Moderator 10+ Year Member

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    We never used steroids in our MBB at UC San Diego. I'd guess that that description just got copy-pasted from one of the other procedures.
     
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  19. nvrsumr

    nvrsumr Member 10+ Year Member

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    Never used steroid with MBBs as a fellow at BWH
     
  20. bedrock

    bedrock Member 10+ Year Member

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    Spent a month with Paul Dreyfuss during my training and I can tell u that that the MBB/RF expert of North America is opposed to steroid in MBB because it affects the accuracy of diagnostic MBB.

    There are several local yahoos in my area that perform their MBB with 1ml of volume at each level and include steroid. Naturally everyone has a positive block and then they fail the subsequent RF performed with equally shoddy technique.

    Then I end up having to explain to the patient why their RF may not have worked, when they end up at my office.

    RF is the only pain procedure with level 1 evidence. Need to perform the blocks and RF with the same techniques as the original study. If not insurance will find a way to take it away from all our patients, because of all the subsequent RF failures.
     
    Last edited: 05.21.14
  21. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    So you use a triple block paradigm to determine who are appropriate RF candidates?
     
  22. emd123

    emd123 5+ Year Member

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    Didn't one of the original studies cited in the ISIS guidelines use "complete pain relief" as the threshold for a positive, also?
     
  23. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    MacVicar style. Give em a squirt of saline and see what happens.
     
  24. bedrock

    bedrock Member 10+ Year Member

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    I strongly advocate for blocks performed with proper technique.

    1-Contrast
    2-small volumes (0.3ml)
    3-no sedation
    4- no steroid.
     
  25. pmrmd

    pmrmd SDN Lifetime Donor Lifetime Donor 7+ Year Member

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    Contrast + small volume anesthetic = larger volume = improper technique = ridiculous CMS criteria = whatever. I wouldn't expect half the people to comprehend that they will get a needle for roughly two hours of benefit. I wouldn't expect even a tenth of them to remember they did well for that small amount of time. Using steroid doesn't mean the volumes have to be large.
     
  26. Yo GabbaPentin

    Yo GabbaPentin 5+ Year Member

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    Whilst training at the MOST prestigious fellowship program at the university of "my d!ck is bigger than yours"... We also used no steroid.

    Only xxxl scrub bottoms.
     
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  27. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    Complete pain relief OF THE OBJECT PAIN. So no, we didn't get rid of ALL of your low back pain. But the pain that we originally attributed to your facet joints? THAT is expected to be completely ablated.
     
  28. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    Here is a PDF of the original study (http://columbiapain.org/documents/2000multifidusemgdenervation.pdf) . Please note, in the first paragraph on page 1271, Drs. Dreyfuss and Bogduk list, as past of their inclusion criteria, "positive for lumbar zygapophysial joint pain after controlled diagnostic blocks." The controlled blocks used in their precursor study included Lidocaine, Marcaine, and saline.

    So again, I ask, since you make yourself out to be as pure as the driven snow, and apparently a better doc than we mere mortals, do you really use a triple block paradigm before moving forward with radiofrequency?
     
  29. bedrock

    bedrock Member 10+ Year Member

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    I refer you to post 23 in this thread.

    All along, I've been talking about the technique of the procedure itself.

    You seemed to be obsessed with doing the procedure three times, which I never proposed.
     
  30. ampaphb

    ampaphb Interventional Spine 7+ Year Member

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    I refer you to post #19 of this thread, where you staed "RF is the only pain procedure with level 1 evidence. Need to perform the blocks and RF with the same techniques as the original study." The methods for patient selection in the original study included a placebo block.
     
  31. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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  32. giddyup

    giddyup ASA Member 7+ Year Member

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    Hi Steve, I read that document you posted and I'm having trouble making out exactly what the conclusion is. Could you translate? It seems to say at the bottom there that performing the medial branch block with steroid is not out of the question and would not necessarily be denied.
     
  33. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    It is comments from pain docs in a medicare region. Just comments.
     

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