PSA: SPPM virtual conference clarifies depo use as not approved… update from SIS says yes

[myrandom2003]

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I am on the virtual conference with society of pain practice management today and they specifically stated:

First coast and Noridian only currently still have depomedrol approved for ESI.
Otherwise, Depomedrol/methylpred is not an accepted steroid for use, by the new medicare guidelines, for ESI.
so if they audit you and you used depo, they will claw back money.

 

[RoloTomassi]

Interesting thanks. Can't find any anyways. Dex it is. Makes no sense that Kenalog is approved

 

[myrandom2003]

Exactly. Every version of Triamcinalone acetate has a "not for epidural use" label on it.
Is there any other version of triamcinalone out there that I am not aware of?

Interestingly, Zilretta does not have that epidural label from I have seen, but it is very expensive and not sure if anyone is comfortable using it in the epidural space.

 

[GoBeers]

so celestone and dex are our options?

 

[myrandom2003]

so celestone and dex are our options?

at least for medicare patients

 

[drrosenrosen]

I am on the virtual conference with society of pain practice management today and they specifically stated:

First coast and Noridian only currently still have depomedrol approved for ESI.
Otherwise, Depomedrol/methylpred is not an accepted steroid for use, by the new medicare guidelines, for ESI.
so if they audit you and you used depo, they will claw back money.

So just to clarify, this is saying that, unless you're under Noridian or First Coast, then depomedrol is disallowed for ESI?

 

[myrandom2003]

So just to clarify, this is saying that, unless you're under Noridian or First Coast, then depomedrol is disallowed for ESI?

Correct, it is not an accepted steroid for use for epidurals. This is according to the people at this seminar. She said at the townhall meeting with the medicare people, they said unless your local LCD specifically mentions depo, it is disallowed

 

[clubdeac]

Unbelievable

 

[drrosenrosen]

Exactly. Every version of Triamcinalone acetate has a "not for epidural use" label on it.
Is there any other version of triamcinalone out there that I am not aware of?

Interestingly, Zilretta does not have that epidural label from I have seen, but it is very expensive and not sure if anyone is comfortable using it in the epidural space

Any chance there was a misprint and they meant to write "80mg of methylprednisolone" instead of "80mg of triamcinolone"? I mean, this is the federal government we're talking about....

 

[Ducttape]

Correct, it is not an accepted steroid for use for epidurals. This is according to the people at this seminar. She said at the townhall meeting with the medicare people, they said unless your local LCD specifically mentions depo, it is disallowed

who is "she"? is it someone who is attached to CMS?

 

[BobBarker]

don’t believe it until you see it in print.

 

[bedrock]

I'm still not buying it.

And I will eat the cost of the depo if needed because it works so much better than dex and even celestone for elderly spine. I can't eat the cost of the epidural however, so I do need to ensure that ESI code is paid no matter what steroid is used.

 

[myrandom2003]

who is "she"? is it someone who is attached to CMS?

She is:

Amy Turner​

RN, MMHC, BSN, CPC, CHIAPP​

Not associated with Medicare but is the main person that does a lot of coding/billing webinars for Society for Pain Practice Management. She references the Medicare townhalls/webinars/etc that attends and responses from them. She stated they specifically left off depomedrol but there was not a reason they did so.

Don't shoot the messenger. Just passing along information that is being put out there.
If anyone wants to continue to use Depo, more power to them.

 

[myrandom2003]

Any chance there was a misprint and they meant to write "80mg of methylprednisolone" instead of "80mg of triamcinolone"? I mean, this is the federal government we're talking about....

I think you take it at face value rather than interpretation until a correction or clarification is filed.

 

[MD87]

Prior CMS guidelines included depo. The link below “supersedes” the prior guidelines, and states:
Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16

These new, most up to date guidelines don’t specifically mention anything regarding the use or non-use of depo. Even the doses listed above are “recommendations,” not mandates. I would imagine it would be very difficult for CMS to audit you and then take money back when they don’t state that you can’t use it.

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

 

[Ferrismonk]

She is:

Amy Turner​

RN, MMHC, BSN, CPC, CHIAPP​

Not associated with Medicare but is the main person that does a lot of coding/billing webinars for Society for Pain Practice Management. She references the Medicare townhalls/webinars/etc that attends and responses from them. She stated they specifically left off depomedrol but there was not a reason they did so.

Don't shoot the messenger. Just passing along information that is being put out there.
If anyone wants to continue to use Depo, more power to them.

Hm. I never trust anyone with more letters after their name than in it.

 

[drrosenrosen]

This reminds me a bit of the whole neurology consultation before kypho thing from last year. We are planning to buy a few boxes of Celestone, but will be keeping a close eye on this and waiting for update and change back to rationality.

 

[SpineandWine]

That’s odd. I gotta switch over from Depo. That’s all I’ve been using except for TFESI (where I use dex)

 

[jsaul]

This reminds me a bit of the whole neurology consultation before kypho thing from last year. We are planning to buy a few boxes of Celestone, but will be keeping a close eye on this and waiting for update and change back to rationality.

i have done probably 15-20 kyphos on medicare patients last year and got paid for all of them. every doc around me who does kypho never got a neurology consultation prior .

 

[Dr. Ice]

The unfounded fear that this Amy creates in us, should be a soul awakening, earth shattering call for all of us, despite our backgrounds to unite against a common enemy. To prove that we will not be told what we can and cannot use or what is in the best interest of OUR patients..we should stand and fight…

Oh wait, it’s just too hard…I think I will just lay down..I will do more PRP, more stim, I will work for a hospital. I will ride the absurd wave of reimbursement. I will listen to KOLs at some crappy steakhouse and go home after 1 beer with my head hanging low thinking I should be more like (he/him) or (she/her). I will become a salesman even though that’s not why I became a doctor.

Amy is powerful, she sleeps well at night..she has no idea what she is doing or talking about..

I must follow Amy..

A modern day doctors tale..

 

[myrandom2003]

First coast LCD Q&A specifically mentions Depomedrol. (Question 6A)
And clarifies some other things too.

Epidural steroid injections (ESI) for pain management

 

[SageCraft]

First coast LCD Q&A specifically mentions Depomedrol. (Question 6A)
And clarifies some other things too.

Epidural steroid injections (ESI) for pain management

7Q. The published LCD states that methylprednisolone 80 mg may be administered. Only Novitas and First Coast have the methylprednisolone in their policy. Other Medicare contractors do not have this drug in their final policy. Is this drug allowed?
7A. No. Please refer to our final published policy as this steroid has been removed.

 

[myrandom2003]

SIS had this to say:

9. What is the steroid dose limit?
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

10. Is methylprednisolone no longer an option for epidural steroid injections?
It is expected that a non-particulate
steroid will be the drug of choice for
ESI. Particulate steroids may be used
under certain circumstances (e.g., failure
to achieve relief with a non-particulate steroid). The language in the LCDs requires use of the lowest effective dose and provides recommendations of agents and dose limits. The policy language would not prohibit the use of methylprednisolone, but it is not included in the list of recommended steroids in some of the LCDs.

* Policies current as of January 18, 2022. SIS will update the list of policies as they are released.

 

[Ronin1]

So for you all using intralaminar dexamethasone. What is your standard dose? 10mg?

 

[RoloTomassi]

So for you all using intralaminar dexamethasone. What is your standard dose? 10mg?

Yes

 

[drrosenrosen]

I guess I'm going to switch to betamethasone, as I still believe my experience that particulate works longer than dex. Until they force me to switch to dex. And then a few years later come out with a new study showing that ESIs don't work and disallowing them altogether.