New Medicare LCD for epidural treatment under proposal

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FYI, limitations are being proposed for Epidural Injection as treatment option for chronic pain

This proposed LCD on Epidural Procedures for Pain Management services was announced on June 10, 2021. This nationwide policy contains many onerous changes that will detrimentally affect patient access to care. ASIPP is aware and already contacting congress members, but getting your patients to complain can also help.

Please see below for important points but one of the bigger points to note is that frequent epidural injections beyond 12 months period may trigger audit, unless you justify by doing additional documentation, including objective functional scores, and must last 3 months
(so 2.5 months of great pain relief will not be acceptable in view of Medicare - is my understanding)

"Covered Indications
Epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following three
(3) requirements are met:
History, physical examination, and concordant radiological image-based diagnostic testing that supports
one of the following5:
Lumbar, cervical or thoracic radiculopathy and/or neurogenic claudication due to central disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis5 OR

* Post-laminectomy syndrome,6,7,8 OR Acute herpes zoster associated pain.6 􀀀


1. AND
Radicular pain is severe enough to cause a significant degree of functional disability or vocational
disability measured at baseline using an objective pain scale*. A functional assessment scale must be
performed at baseline if function is considered as part of the assessment.

AND
Pain duration of at least four (4) weeks
, and the inability to tolerate noninvasive conservative care or
medical documentation of failure to respond to four (4) weeks of noninvasive conservative care or acute
herpes zoster refractory to conservative management where a four (4) week wait is not required.9

2. The ESIs must be performed under CT or fluoroscopy image guidance with contrast.10
Transforaminal epidural steroid injections (TFESIs) involving a maximum of two (2) levels in one spinal region
are considered medically reasonable and necessary. It is important to recognize that most conditions would not
ordinarily require ESI at two (2) levels in one spinal region.
3.
Caudal epidural steroid injections (CESIs) and interlaminar epidural steroid injections (ILESIs) involving a
maximum of one level are considered medically reasonable and necessary.
4.
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
6.
7. The ESI injectants must include corticosteroids, anesthetics, anti-inflammatories and/or contrast agents.1
8. The ESIs should be performed in conjunction with conservative treatments.9
9. Patients should be part of an active rehabilitation program, home exercise program or functional restoration program.10,11
*Note: The scales used to measure pain and/or disability must be documented in the medical record. Acceptable scales include, but are not limited to: Verbal rating scales, Numerical Rating Scale (NRS) and Visual Analog Scale (VAS) for pain assessment, and Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry
Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Scale (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the PROMIS profile domains to assess function.

Limitations
Injections performed without image guidance or by ultrasound are not considered medically reasonable and
necessary.12,13,14
1. The ESIs performed with biologicals or other substances not FDA designated for this use are considered not medically reasonable and necessary.
2. It is not considered medically reasonable and necessary to perform multiple blocks (ESIs, sympathetic blocks, facet blocks, trigger point injections, etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session.
3. Use of General Anesthesia, Moderate Sedation and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore, is not considered medically reasonable and necessary.15 In exceptional cases documentation must clearly establish the need for such sedation in the specific patient.
4. The ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, or cervicogenic headaches are considered investigational and therefore are not considered medically reasonable and necessary.6,16,17
5. The ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.
7
6.It is not considered medically reasonable and necessary for more than one spinal region to be injected in the same session.
7. It is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.
8. It is not considered medically reasonable and necessary to perform CESIs or ILESIs at more than one (1) level during the same session.
9.
10. It is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally.13
11. It is not medically reasonable and necessary to perform ESIs in a series.8
Steroid dosing should be the lowest effective amount and not to exceed 40mg for methyl prednisone, 10-20mg for triamcinolone acetate, and 10mg (10mg/mL) for dexamethasone phosphate per session.15
12. It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.18,19 Frequent continuation of epidural steroid injections over 12 months may trigger a focused medical review. Use beyond twelve months requires the following:
13. Pain is severe enough to cause a significant degree of functional disability or vocational disability. The ESI provides at least 50% sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline).

Rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months.

Communication with primary care provider regarding patients’ candidacy for prolonged repeat steroid use.

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My eyes kind of glazed over towards the end but it sounds like most of us are already following the above guidelines(?) Which part is different?
 
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there's a lot of bullet points that can be used to go over your documentation with a fine toothed comb
 
Members don't see this ad :)
With the exception of the 12 month limitation, this is no different than what I've been doing for the past 10 years.

do people use epidurals differently?
 
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My exception: I have used depomederol 80 mg at times in the past.
 
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Would want to allow for booster ESI at 2 weeks if failing PT with radicular pain.
Repeat ESI within 30 days after partial relief was on the first draft I think but now has been eliminated.
 
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This is insane. Some people get an ESI prior to 4 weeks of they’re miserable. Sometimes a repeat injection sooner than three months if still painful and limited. Some people have ongoing pain but aren’t surgical candidates so their plan of care extends over 12 months. Medicare enrollees are going to be rightfully upset. I can’t imagine having a happy patient population within these guidelines.
 
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So more self pay patients?

I have patients that I do an ESI every 6 months on. I have patients that get relief for a month or so and we hit em again

I have patients that come in with acute radic

Very stupid. Its all cost cutting. I dont really get where the $ goes - inflation is increasing, cost of living is increasing, premiums for health insurance are increasing - how is it ok to always be getting cut every year (or threatened at least) - we should have increases in payments and reimbursable procedures. I know its all going to share holders and execs - but what the hell is medicare doing with it.
 
I guess I’m gonna be doing a lot more free work to not risk losing patients in a competitive market.
 
So more self pay patients?

I have patients that I do an ESI every 6 months on. I have patients that get relief for a month or so and we hit em again

I have patients that come in with acute radic

Very stupid. Its all cost cutting. I dont really get where the $ goes - inflation is increasing, cost of living is increasing, premiums for health insurance are increasing - how is it ok to always be getting cut every year (or threatened at least) - we should have increases in payments and reimbursable procedures. I know its all going to share holders and execs - but what the hell is medicare doing with it.
When CMS admin spoke at asipp meeting to speak on the facet guidelines they let us know that cost has nothing to do with their decisions. So now you can rest easy
 
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I realize that there are bad actors that they need to get a handle on. But putting these one size fit all LCDs out limits our ability to treat the patients individually. This will result in more pills and more fusions. Strong work CMS.
 
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as a counterpoint:

if we are routinely doing more than 4 epidurals per year Medicare patients and not getting at least 50% decrease in pain for 3 months, are we really doing patients a favor?
 
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Members don't see this ad :)
as a counterpoint:

if we are routinely doing more than 4 epidurals per year Medicare patients and not getting at least 50% decrease in pain for 3 months, are we really doing patients a favor?
That is the least contentious point of the LCD.
 
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I thought these LCD's were local, depending on your particular medicare carrier
 
as a counterpoint:

if we are routinely doing more than 4 epidurals per year Medicare patients and not getting at least 50% decrease in pain for 3 months, are we really doing patients a favor?
I 100% agree. However… for the couple people who may benefit from something outside of the box. We now must tell them they are out of luck. And I have to tell acute radicular pain/HNP 10/10 people to just wait for 4 weeks.

It does limit my ability to adapt my plan for certain individual patients and go even more cookie cutter medicine. I might as well stop seeing patients in clinic and just put up a pain kiosk where they can put in all of their specifics. Then the government can tell them what the treatment is.
 
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I 100% agree. However… for the couple people who may benefit from something outside of the box. We now must tell them they are out of luck. And I have to tell acute radicular pain/HNP 10/10 people to just wait for 4 weeks.

It does limit my ability to adapt my plan for certain individual patients and go even more cookie cutter medicine. I might as well stop seeing patients in clinic and just put up a pain kiosk where they can put in all of their specifics. Then the government can tell them what the treatment is.
100x this.
 
My eyes kind of glazed over towards the end but it sounds like most of us are already following the above guidelines(?) Which part is different?
Biggest issue for me is 1- medicare requiring 4 weeks of conservative care, and 2- limits of steroid.

I mandate PT before a CESI due to the risk of a CESI, but I'd rather go straight to a lumbar epidural for lumbar stenosis (which is not going to resolve with just PT most of the time).

I use 80 of depo for a caudal due to the diffuse nature of the injection and I don't appreciate a bureaucrat interfering with that who doesn't understand medicine.

Are they not going to pay for an ESI with 80 of depo, or just the J code for the depo? (for office based procedures)

I'm not going to worry about the $1.20 from that J code though the procedure needs to be covered.
 
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Biggest issue for me is 1- medicare requiring 4 weeks of conservative care, and 2- limits of steroid.

I mandate PT before a CESI due to the risk of a CESI, but I'd rather go straight to a lumbar epidural for lumbar stenosis (which is not going to resolve with just PT most of the time).

I use 80 of depo for a caudal due to the diffuse nature of the injection and I don't appreciate a bureaucrat interfering with that who doesn't understand medicine.

Are they not going to pay for an ESI with 80 of depo, or just the J code for the depo? (for office based procedures)

I'm not going to worry about the $1.20 from that J code though the procedure needs to be covered.
Bill for 40 and give 40 for free. Any literature on steroid dosing?
 
I think there dex study that 4 mg is as good as any.

For particulate, I used to use 80 mg for IL for years, then my then practice wanted to be cheap and only bought 40 mg. I noticed no difference.
 
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I think there dex study that 4 mg is as good as any.

For particulate, I used to use 80 mg for IL for years, then my then practice wanted to be cheap and only bought 40 mg. I noticed no difference.
 
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I think there dex study that 4 mg is as good as any.

For particulate, I used to use 80 mg for IL for years, then my then practice wanted to be cheap and only bought 40 mg. I noticed no difference.
Agree with 40 of depo for ILESI, just not for caudal, unless your target is L5-S1.
 
40mg of depomedrol on back order. Interestingly at around the time this LCD came out 🤔
 
Is this saying no repeat injection for three months from the first? Sometimes, I do two a month apart if they have partial relief.
 
This is a national policy, like kypho last year and facet intervention this year. We all suffer equally and complain in unison.
What happened with kyphoplasty last year?
 
This is terrible for acute radic. Do a TFESI and pain comes back in a couple weeks, I guess the patient is just screwed and needs to wait 3 months.

why even include steroid dose in this? The LCD is written as if there is enormous amounts of data showing steroid is clear cut.

12 month limit, and then patient needs surgery? WTF is that. It’s like the facet LCD saying Yoj can’t do a trial of MBB at a fusion level, as if Yoj have a fusion and it’s a slam dunk yojr back pain is cured.
 
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How often do the private insurers instantly adopt Medicare rules and even at times take them a step or two further?
 
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Waiting 4 weeks for acute exacerbations of spinal stenosis is going to piss off 10-20% of my MC patients, who, in turn, are going to cause 90% more headaches for me because it will somehow be my fault. Referring docs will be pissed because they will demand repeat injections for partial relief, which I won't be able to do. And all this crap for $90? And I can't jack up my rates for inflation like every other business (in fact, get paid less next year)? Screw that. This is going to exponentially expedite my retirement, so perhaps its good after all.
 
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My problem is for the acute radic patients. Sure this works for the stable spinal stenosis patients but the acute radic patients are going to get screwed. There needs to be exceptions!

Goodbye medicine…. I’m going to start studying for my series seven

what they SHOULD have in this stupid LCD is an epidural for pain can only be billed by a board certified pain physician. Physician being the key word
 
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i dont understand why they always trying to screw us for a 100 dollar procedure that many patients want. Why not go after all the unnecessary fusions that are way more expensive and causes real permanent issues in patients.
 
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i dont understand why they always trying to screw us for a 100 dollar procedure that many patients want. Why not go after all the unnecessary fusions that are way more expensive and causes real permanent issues in patients.
Because it isn’t a $100 procedure. A 2 level transforaminal done in the HOPD setting costs Medicare nearly $1000. A caudal, over $600.
 
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The majority of these procedures are not done in hospital ORs
 
some are reasonable guidelines, but really this is restricting us too much. is it too late to send patient letters?
 
from someone who sees more Medicaid and Managed plans than the norm, I have essentially been following these same rules for the past 8 years.

there have not been any real issues. and in fact, it is good because it means the patient has to take more responsibility ie start doing exercises and stretches instead of x-box 24/7.

for the LOL population, I am not seeing this ton of acute radics. disc herniation in a 90 year old?
 
-when did your pain start?
a week ago
-are you SURE you didnt feel a little twinge a month ago?


biggest problem is that these guidelines discourage ESIs after a year. basically telling the LOL with stenosis that she HAS to have a laminectomy (or other surgical procedure) or be in pain.
 
agreed, yet there is the biggest catch in there - its easy to document "patient does not desire surgery and last injection helped >50% for 3 months."




put that in a smartphrase.
 
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-when did your pain start?
a week ago
-are you SURE you didnt feel a little twinge a month ago?


biggest problem is that these guidelines discourage ESIs after a year. basically telling the LOL with stenosis that she HAS to have a laminectomy (or other surgical procedure) or be in pain.
Yep. ISP device numbers going to skyrocket.
 
agreed, yet there is the biggest catch in there - its easy to document "patient does not desire surgery and last injection helped >50% for 3 months."




put that in a smartphrase.
yes the biggest issue is what to after 12 mo, I have many medicare patients that see me for lumbar esi once or twice a year for spinal stenosis. it allows them to function and do ADLs and not be on pain meds. What to do for them. they dont want surgery. So if they don't want surgery they can still get injections past 1 year and ongoing?
 
Most of these old people are not great surgical candidates anyway. According to this, if you document that, or that they were improved >50% for more than 3 months, you can extend the injections beyond 12 months
 
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yes the biggest issue is what to after 12 mo, I have many medicare patients that see me for lumbar esi once or twice a year for spinal stenosis. it allows them to function and do ADLs and not be on pain meds. What to do for them. they dont want surgery. So if they don't want surgery they can still get injections past 1 year and ongoing?
that's what the LCD says. just document that.
 
Why can’t they just say 3 or 4 per 12 mos or calendar year. I have plenty of people that are 50-60% after first and then I do another a month later and we are 80+ and they are fine with that relief.
 
some are reasonable guidelines, but really this is restricting us too much. is it too late to send patient letters?
I don't think it's too late. Here's update from ASIPP - click on the link

 
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