Medicare epidural LCD concern

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bedrock

bedrock

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Question for the group. Here is section 5 of the new medicare LCD

5. It is considered medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated.
Repeat ESI when the first injection directly and significantly provided improvement of the condition being
treated may be considered medically reasonable and necessary when the medical record documents at least
50% of sustained improvement in pain relief for at least three months and/or improvement in function
measured from baseline using SAME scale* for at least three months.7,8

I'm not sure in the future how to handle the very common scenario of the first medicare epidural not working for long or as well as the limits in this paragraph, and so the second epidural now can't be offered for 3 months? Or ever????

Question #1, if you provide a patient with exactly 50% relief after one epidural, then you can't do another ESI for 3 months or you don't get paid for the second one? Even commercial insurance allows me to repeat an epidural immediately if the patient obtains 50% relief with the first epidural.

Question #2- What about patients with unclear pathology? We've all see plenty of destroyed medicare spines, and you have a 50/50 chance of ESI #1 working vs injection target #2? Are those patients just screwed if you're wrong the first time?

Question #3- This is mainly for lumbar stenosis. To keep everyone happy (referring surgeons, patients, PCP), I generally do a TFESI with dex right at the stenosis the first time. If that gives them good but brief relief, I follow up with a ILESI/caudal/S2 TFESI with depomedrol, and most but not all of those patients are better for 4-8 months.

This is now my approach, because I used to just start with a ILESI/caudal/S2 with depomedrol, and if didn't work, then I would do a TFESI with dex right at the worst stenosis level. Most of the time, this second ESI with dex only gave brief relief, but rarely those TFESI with dex right at the pathology will work better than a ILESI/caudal/S2 with depomedrol. It would be nice to have both options. I find that patients and surgeons just can't understand injecting far away from the pathology for the first ESI.

#4- The reality is that Medicare patients often need two ESI within a 4 week period to truly help them. I wondering if I have to start telling my medicare patients that they must pay cash for a second epidural if the first one gave them great relief, but only for a week (as dex often does)?

#5- What the hell is the SAME scale? I googled but didn't find it.

#6- Generally speaking, medicare has been much more picky about TFESI than ILESI for the past decade.
The paragraph from the medicare LCD above, does start with TFESI. I wonder if you do a TFESI with dex first, and then follow up with an ILESI/Caudal with depo, if they will still hassle you about the second medicare epidural in 3 months, particularly as it is a different CPT code?

Thoughts?
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Same scale just means you used the same one. But good questions, Medicare patients are just going to be out of luck. I don't see a way of doing a second ESI within 3 months.
 
I’ve been doing more caudal with depo medrol lately and will have to continue this. Definitely better relief than the TF ESI with dex.
 
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I thought is said somewhere can do a second one 14 days later at different level or approach if less than 50% improvement?
 
We can't use Depo in the epidural space at all in Michigan. It's removed from our LCD. Per our Medicare rep.
 
Can't bill for ESI CPT if Depo is used in epidural space. This has been discussed in the "Depo Outlawed" thread.
 
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SageCraft said:
Can't bill for ESI CPT if Depo is used in epidural space. This has been discussed in the "Depo Outlawed" thread.
Click to expand...
Ducttape said:
your LCD does not say you cannot use depo. it says you should not exceed the 3 other steroids - triamcinolone, betamethasone, or dexamethasone.

that being said, i would either use 10 mg dex or 6-12 mg betamethasone...
Click to expand...
Duct is correct. Your Michigan Medicare rep is wrong.

This was discussed previously and maybe u came to a different conclusion, but the rest of us interpret the new rules to limit the doses of steroid but not ban depo completely from an epidural.

If you disagree please post clearly written national guidelines to the contrary.
Your one local rep is not sufficient, as we know how well educated these people generally are.
 
I agree with not trusting our Medicare rep had it not been for Manchikanti's ASIPP presentation discussing the topic.
 
so tell me why methylprednisolone was specifically sorted out. what is it about that medication that makes Medicare Michigan not want to cover it? how is its mechanism different?
 
Ducttape said:
so tell me why methylprednisolone was specifically sorted out. what is it about that medication that makes Medicare Michigan not want to cover it? how is its mechanism different?
Click to expand...
I would love to know the answer to this. We still don't have a reason and I believe Manchikanti is still waiting on clarification from Medicare. Interlaminar Dex doesn't hold a candle to Depo in my experience.
 
I would like to return this thread to the topic. I started this thread because the other two Medicare threads covered other topics or veered off topic.

The question of this thread and what I’d like to discuss is doing an epidural on a Medicare patient more frequently than once every three months and if that is possible to do while still getting paid. Can we please focus on that question?
 
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bedrock said:
I would like to return this thread to the topic. I started this thread because the other two Medicare threads covered other topics or veered off topic.

The question of this thread and what I’d like to discuss is doing an epidural on a Medicare patient more frequently than once every three months and if that is possible to do while still getting paid. Can we please focus on that question?
Click to expand...
The answer to your question is contained in the next sentence of the LCD. It is actually section 6, not section 5. Maybe you are looking at an outdated version of the LCD? Link below to the most up-to-date LCD.

"6. Repeat ESI when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using SAME scale* for at least three months.7,8 If a patient fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, with the rationale and medical necessity for the second ESI documented in the medical record."

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.
www.cms.gov www.cms.gov
 
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SageCraft said:
I would love to know the answer to this. We still don't have a reason and I believe Manchikanti is still waiting on clarification from Medicare. Interlaminar Dex doesn't hold a candle to Depo in my experience.
Click to expand...
It looks the the LCD has been updated to include methylprednisolone now.

"12. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16"

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.
www.cms.gov www.cms.gov
 
No_Pain_No_Gain said:
It looks the the LCD has been updated to include methylprednisolone now.

"12. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16"

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.
www.cms.gov www.cms.gov
Click to expand...
No_Pain_No_Gain said:
The answer to your question is contained in the next sentence of the LCD. It is actually section 6, not section 5. Maybe you are looking at an outdated version of the LCD? Link below to the most up-to-date LCD.

"6. Repeat ESI when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using SAME scale* for at least three months.7,8 If a patient fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed using a different approach, level and/or medication, if appropriate, with the rationale and medical necessity for the second ESI documented in the medical record."

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.
www.cms.gov www.cms.gov
Click to expand...
Thank you no pain no gain!

My bad here in that I posted my question regarding #5 using a paragraph copy/pasted from the original Medicare thread on SDN, not from CMS. Thankfully my concerns have been relieved with your post and the official medicare site, which I have reviewed.

I do wonder if medicare recently updated both of these guidelines, not just the depomedrol part, after hearing feedback from prominent pain physicians? If so good for medicare.

The reality is that 1- new medicare patients often require two epidurals initially before you find what works for them, but yes after that limiting repeat epidurals to 3 months or longer does make sense.
2- being able to use depomedrol in epidurals is critical, because it lasts long enough to preventing unnecessary spinal surgeries, and this is ultimately better both for patients and the government as fewer surgeries saves medicare lots of money.
2a-it is always inappropriate to use more than 80mg of depomedrol for any epidural.

Weirdly refreshing to see a federal agency post guidelines that truly make sense, but these are reasonable.

This should help shut down unscrupulous docs who do a series of three epidurals on everyone no matter how well they are doing, or do monthly epidurals, not for patient benefit, but to have a consistent revenue stream.
 
No_Pain_No_Gain said:
It looks the the LCD has been updated to include methylprednisolone now.

"12. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16"

LCD - Epidural Steroid Injections for Pain Management (L36920)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.
www.cms.gov www.cms.gov
Click to expand...
The LCD you have linked (L36920) does not represent Michigan. Our LCD is L39054. Methylprednisolone is still removed.

"Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 12 mg of betamethasone, and 15 mg of dexamethasone per session"

LCD - Epidural Steroid Injections for Pain Management (L39054)
 
Again this gets back to my question of whether or not medicare will simply not pay the j code for an epidural with depomedrol, or if they will also deny the procedure CPT codes if the epidural is performed with depomedrol?

Can anyone answer this?

The LCDs specifically forbid biologics as well for epidurals, so medicare doesn't want to pay for PRP epidurals, which understandable given the level of the science, but I'm wondering if medicare will deny your entire epidural if you use a depo Jcode right now?

I'm thinking of removing J codes from all my medicare epidurals to be safe as my local ESI LCD, doesn't include methylprednisolone.
 
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dc2md said:
I’ve been doing more caudal with depo medrol lately and will have to continue this. Definitely better relief than the TF ESI with dex.
Click to expand...
Agree, though sometimes the medication just spreads where it wants to. Just had a patient, young patient come back after I did a caudal for her and she said it was the best epidural she had ever had, but was still hurting on the left. Tried a repeat caudal yesterday and even after directing the needle all the way to the left/alternating with/without the needle turned to the left, most of the medication still spread to the right.

This is why I frequently do S2 TFESI with depo. One, you can make more with this than a caudal and only takes 60 seconds longer for a bilateral S2, and sometimes is faster depending on the body habitus/sacral curve. Secondly, if you have a patient with largely unilateral symptoms, you can definitely safely direct the depo to one side, which has provided better relief for some patients IMHO.
 
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bedrock said:
Agree, though sometimes the medication just spreads where it wants to. Just had a patient, young patient no less come back after I did a caudal for her and she said it was the best epidural she had ever had, but was still hurting on the left. Tried a repeat caudal yesterday and even after directing the needle all the way to the left/alternating with/without the needle turned to the left, most of the medication still spread to the right.

This is why I frequently do S2 TFESI with depo. One, you can make more with this than a caudal and only takes 60 seconds longer for a bilateral S2, and sometimes is faster depending on the body habitus/sacral curve. Secondly, if you have a patient with largely unilateral symptoms, you can definitely safely direct the depo to one side, which has provided better relief for some patients IMHO.
Click to expand...

Does a 1 level unilateral TFESI pay better than ILESI/Caudal? I thought 2 level and bilateral TFESI paid better but unilateral 1 level paid less based on the ASIPP chart, but could be wrong.
 
bedrock said:
Agree, though sometimes the medication just spreads where it wants to. Just had a patient, young patient no less come back after I did a caudal for her and she said it was the best epidural she had ever had, but was still hurting on the left. Tried a repeat caudal yesterday and even after directing the needle all the way to the left/alternating with/without the needle turned to the left, most of the medication still spread to the right.

This is why I frequently do S2 TFESI with depo. One, you can make more with this than a caudal and only takes 60 seconds longer for a bilateral S2, and sometimes is faster depending on the body habitus/sacral curve. Secondly, if you have a patient with largely unilateral symptoms, you can definitely safely direct the depo to one side, which has provided better relief for some patients IMHO.
Click to expand...
Interesting re the S2.

However, how many of these truly can’t have an interlam paramedian L5S1 on the symptomatic side? Unless prior posterior surgery at the level or high-grade listhesis, that is what I do typically. Caudal if L5s1 anatomy precludes.
If bilateral symptoms and interlam flow is too unilateral with about half my injectate, it takes me maybe 30 seconds to retract tip a little, cross midline and re-obtain LOR under clo for the remainder of the meds.
 
Taus said:
Interesting re the S2.

However, how many of these truly can’t have an interlam paramedian L5S1 on the symptomatic side? Unless prior posterior surgery at the level or high-grade listhesis, that is what I do typically. Caudal if L5s1 anatomy precludes.
If bilateral symptoms and interlam flow is too unilateral with about half my injectate, it takes me maybe 30 seconds to retract tip a little, cross midline and re-obtain LOR under clo for the remainder of the meds.
Click to expand...
Depends on the issue. For central stenosis, yes there is often, but not always an intact level below for an ILESI. However, in my years of experience in different PP clinics, I mostly see patients with residual lateral recess stenosis after poor lamis, foraminal stenosis after lami, and patients with recurrent radiculopathy from broad degenerative disc bulges often in combination with the lateral recess stenosis. Medicare patients with stenosis and virgin spines are maybe 10 percent of the spine patients that I see.

So most patients that I have seen for the past dozen years need an alternative approach besides ILESI with depo, but I agree its the place to start with medicare patients.

And as I mentioned, caudals don't often go where you want them to go, even if you move the needle all the way to one side or the other. And a S2 is better for consistent unilateral flow when needed.
 
MD87 said:
Does a 1 level unilateral TFESI pay better than ILESI/Caudal? I thought 2 level and bilateral TFESI paid better but unilateral 1 level paid less based on the ASIPP chart, but could be wrong.
Click to expand...
In the ASC TFESI slightly yes, in the office, slightly no. ILESI pays slight better than unilateral TFESI in office.

But I'm talking about whats best for the patient here, not making 10 more dollars.
 
You guys ever do a caudal with a catheter in order to inject incrementally at different levels?
 
bedrock said:
Question for the group. Here is section 5 of the new medicare LCD

5. It is considered medically reasonable and necessary to perform TFESIs bilaterally only when clinically indicated.
Repeat ESI when the first injection directly and significantly provided improvement of the condition being
treated may be considered medically reasonable and necessary when the medical record documents at least
50% of sustained improvement in pain relief for at least three months and/or improvement in function
measured from baseline using SAME scale* for at least three months.7,8

I'm not sure in the future how to handle the very common scenario of the first medicare epidural not working for long or as well as the limits in this paragraph, and so the second epidural now can't be offered for 3 months? Or ever????

Question #1, if you provide a patient with exactly 50% relief after one epidural, then you can't do another ESI for 3 months or you don't get paid for the second one? Even commercial insurance allows me to repeat an epidural immediately if the patient obtains 50% relief with the first epidural.

Question #2- What about patients with unclear pathology? We've all see plenty of destroyed medicare spines, and you have a 50/50 chance of ESI #1 working vs injection target #2? Are those patients just screwed if you're wrong the first time?

Question #3- This is mainly for lumbar stenosis. To keep everyone happy (referring surgeons, patients, PCP), I generally do a TFESI with dex right at the stenosis the first time. If that gives them good but brief relief, I follow up with a ILESI/caudal/S2 TFESI with depomedrol, and most but not all of those patients are better for 4-8 months.

This is now my approach, because I used to just start with a ILESI/caudal/S2 with depomedrol, and if didn't work, then I would do a TFESI with dex right at the worst stenosis level. Most of the time, this second ESI with dex only gave brief relief, but rarely those TFESI with dex right at the pathology will work better than a ILESI/caudal/S2 with depomedrol. It would be nice to have both options. I find that patients and surgeons just can't understand injecting far away from the pathology for the first ESI.

#4- The reality is that Medicare patients often need two ESI within a 4 week period to truly help them. I wondering if I have to start telling my medicare patients that they must pay cash for a second epidural if the first one gave them great relief, but only for a week (as dex often does)?

#5- What the hell is the SAME scale? I googled but didn't find it.

#6- Generally speaking, medicare has been much more picky about TFESI than ILESI for the past decade.
The paragraph from the medicare LCD above, does start with TFESI. I wonder if you do a TFESI with dex first, and then follow up with an ILESI/Caudal with depo, if they will still hassle you about the second medicare epidural in 3 months, particularly as it is a different CPT code?

Thoughts?
Click to expand...
the LCD for Noridian is L39240. It's not finalized yet as of today (but I think it will be soon)

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID
www.cms.gov www.cms.gov
 
08C916DC-5DC1-470C-9002-6660DF2D05E0.jpeg
 
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I do paramedian ILESI or caudal ESI with betamethasone. I seem to get decent responses. The vast majority of pts see a temporary reduction in pain of around 40% or so with the first one and the second is usually the clincher. Doing 1 or 3 is far less common. I don't like doing TFESI. I'm always worried about hitting the nerve root. The surgeons seem to always request it, especially when there is severe foraminal stenosis at the level they're requesting to be injected. It's more painful for the pt or I'm just not great at performing them. My ILESI almost always results in minimal pain other than the 30g stick and a couple of seconds of burning from lidocaine.

I'm not gung ho on injections anymore and i try to persuade pts away from them but there is definitely a time and place. It would be a shame to limit them for my pts. I'll probably still do them and just eat the loss if that's the case. I don't even care if it's a placebo effect that gets the pts better just as long as they improve.

I'm also going to call the surgeons and tell them my thoughts on the TFESI. Not to sound like a douche but if they don't agree it would probably be better to refer elsewhere.

Are TFESI relatively painless for the rest of you out there in SDN land? Maybe my technique is wack, lol.
 
Most of the time well tolerated. I try to stay at the very top of the foramen just under pedicle, with a squared up trajectory in relation to endplates, advance very slowly when getting close to foramen and tell the patient to let me know if they start feeling anything down the leg so I can back off or redirect, then inject slowly. Usually get some paresthesia pushing the meds but no more than mild to moderate, tolerable for the few secs. On average more discomfort than IL but not much more.
 
we do far more TFESIs in fellowship than ILESI.

Pretty well tolerated and as described above if you go high up in the foramen, under the pedicle, you’re less likely to hit the nerve root.

One thing I’ve learned from a few of our attendings is that if you’re doing a TFESI, if you see some contrast heading medial to the pedicle, that’s good enough. Don’t advance the needle further to get an even prettier picture because that’s how most people end up getting a paresthesia.
 
gaspasser127 said:
One thing I’ve learned from a few of our attendings is that if you’re doing a TFESI, if you see some contrast heading medial to the pedicle, that’s good enough. Don’t advance the needle further to get an even prettier picture because that’s how most people end up getting a paresthesia.
Click to expand...

Agree - I find a lot of times with moderate to severe stenosis spines the enemy of good is perfect. Hard to get perfect flow. I use SIS guidelines - stay superior in foramen, once we get some medial flow just take it and inject the real stuff.

I do fiddle around with it more in a young person or case of disc herniation without stenosis to get more "textbook" flow.
 
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