Repeat lumbar RFA time restrictions

[bedrock]

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I’ve been told and read in a few LCDs , but not all, that a patient needs repeat their RFA within 2 years or insurance won’t cover it.

So if a patient comes back after 3 years, they have to repeat MBB to ensure insurance will cover it.

Obviously If they have spine surgery in between, they need to repeat MBB.

But for folks at 2.5 years , 3.5 years post PFA, who did well for +2 years after RFA, how do you all handle this?

 

[BobBarker]

Repeat the blocks.

 

[SSdoc33]

it is a huge hassle for the legacy patients who have done well after their sucecssful RFs. sometimes they dont come back until > 2 years. sometimes, they just miss the cutoff.

so, we are talking about a clinic visit to document everything, PT if there hasnt been any recent therapy, a mbb, a f/u, another mbb, another f/u, then the RF.

instead of just going right to RF.

that is a tough sell. id be pissed if i had to do that if it were my back

 

[RoloTomassi]

I just document date, relief %, and duration, then repeat the RF. Not sure if that's wrong but have not had a denial that I know of

 

[SSdoc33]

I just document date, relief %, and duration, then repeat the RF. Not sure if that's wrong but have not had a denial that I know of

It’s not going thru on the facility side. Maybe the billers haven’t caught on, but for Medicare, they are watching like a hawk

 

[MitchLevi]

Repeat the MBB x 2. You didn’t make the rules, and on the bright side that’s two additional facet interventions which literally take 60 sec.

 

[SSdoc33]

How do you guys time it now?

Mbb the 2 week fu then mbb then another 2 week fu?

Can anyone get the RF authorized after the second mbb without a formal fu?

 

[MitchLevi]

I am just recently doing tele, but my PA sees them too

 

[RoloTomassi]

Cutoff is 2 years?

 

[SSdoc33]

Cutoff is 2 years?

Yeah. It’s in the LCD

 

[BobBarker]

If they don’t want to repeat blocks, they have to pay cash. Their choice.

 

[bedrock]

If they don’t want to repeat blocks, they have to pay cash. Their choice.

I feel a bit bad for this patient as they have insurance that pays me well but they have a high deductible.
However, they are also 300lbs, I had to use 98% of the 15cm cannula last time, so I suppose I deserve some extra $$.

 

[painfree23]

I feel a bit bad for this patient as they have insurance that pays me well but they have a high deductible.
However, they are also 300lbs, I had to use 98% of the 15cm cannula last time, so I suppose I deserve some extra $$.

Maybe facet arthopathy isn’t their biggest problem…

 

[drrosenrosen]

How do you guys time it now?

Mbb the 2 week fu then mbb then another 2 week fu?

Can anyone get the RF authorized after the second mbb without a formal fu?

so glad non-HOPD is excluded from this bs rule (for now). We just do MBB (2wks) MBB (2wks) RFA

 

[SSdoc33]

Maybe facet arthopathy isn’t their biggest problem…

fatties typically have a lot of facet OA, i find

 

[bedrock]

fatties typically have a lot of facet OA, i find

Maybe facet arthopathy isn’t their biggest problem…

RFA really helped this patient for over two years. Not everything is solved with weight loss.

 

[cowboydoc]

How do you guys time it now?

Mbb the 2 week fu then mbb then another 2 week fu?

Can anyone get the RF authorized after the second mbb without a formal fu?

2-3 weeks apart, phone f/u with my staff days after MBB. Only do in office f/u if response is not clearly elucidated with the phone call. Templated form for nursing staff to complete and submit to insurance for auth.

 

[No_Pain_No_Gain]

Yeah. It’s in the LCD

That is not completely accurate.

In the Palmetto LCD (L38765) it states, "If there is an extended time, 2 years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."

Thus, if the patient had great pain relief for 2.5 years then returns with the exact same pain symptoms having returned with positive facet loading on examination, then i don't think there is a question as to the source of the pain and I go straight to RFA.

 

[SgtThunderfistMD]

so glad non-HOPD is excluded from this bs rule (for now). We just do MBB (2wks) MBB (2wks) RFA

This is what I do in HOPD too. Never had a denial. Office visits in between each step have never made $en$e to me when people mention doing it on here.

 

[Tboned]

That is not completely accurate.

In the Palmetto LCD (L38765) it states, "If there is an extended time, 2 years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."

Thus, if the patient had great pain relief for 2.5 years then returns with the exact same pain symptoms having returned with positive facet loading on examination, then i don't think there is a question as to the source of the pain and I go straight to RFA.

This could be interpreted either way. Especially because it is and/or. If it’s greater than 2.5 years this could be interpreted as you need to repeat blocks. Not saying that is right for the patient or clinically needed. I’d try and repeat RFA. Curious if youre getting paid?

 

[Tboned]

How do you guys time it now?

Mbb the 2 week fu then mbb then another 2 week fu?

Can anyone get the RF authorized after the second mbb without a formal fu?

All the time. patient sends in pain log. Reviewed by me. Clearly positive, RFA ordered. Clinic assistant drops brief note in chart. Prior auth team screens. RFA done.

If pain log looks wonky, followup scheduled with me to discuss.

I’ve said this before, my patients hate coming to see me to tell me blocks were positive, which I already know from their pain log. I think it’s ridiculous to make every patient followup after MBB. Only reason to do this is to fulfill insurance requirements. Otherwise it is done to pad the bank.

If they have questions about RFA, which I discuss at the time of ordering MBB, then happy to discuss again in followup. I also actually talk to my patients during their procedures visits. A lot of times any questions regarding this stuff can be answered while the patient is on the table during MBB if need be.

 

[Ducttape]

This is what I do in HOPD too. Never had a denial. Office visits in between each step have never made $en$e to me when people mention doing it on here.

one insurance (an option plan where the initials start with the letter before N and end with 2 letters after N) had required an office visit between each of the injections - to document efficacy and improvement in functionality and document a physical exam.

to OP - ask for auth. see if they will give prior auth for RFA. ive had to do this a lot, and depending on the carrier, it may get approved.

if not, then do 1 MBB. after successful MBB, document that patient had successful RFA that lasted >6 months and reduced pain by >50% and successful Differential MBB that provided >80% reduction for the appropriate duration of the local anesthetic. i dont usually make a follow up appointment after this differential MBB - i just do it at that visit.

 

[SSdoc33]

That is not completely accurate.

In the Palmetto LCD (L38765) it states, "If there is an extended time, 2 years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."

Thus, if the patient had great pain relief for 2.5 years then returns with the exact same pain symptoms having returned with positive facet loading on examination, then i don't think there is a question as to the source of the pain and I go straight to RFA.

this is the same language that I see in the LCD we use.

and it is this exact language that has been used to deny a repeat RF if it was > 2 years. i suspect you are getting more denials than you realize, you arent getting paid, or medicare will be clawing back some of the $$$.

if not, more power to you....

 

[Welcome123]

I’ve been told and read in a few LCDs , but not all, that a patient needs repeat their RFA within 2 years or insurance won’t cover it.

So if a patient comes back after 3 years, they have to repeat MBB to ensure insurance will cover it.

Obviously If they have spine surgery in between, they need to repeat MBB.

But for folks at 2.5 years , 3.5 years post PFA, who did well for +2 years after RFA, how do you all handle this?

Do a predetermination with the insurance for RF if not repeat block algorithm-per whatever tribal custom the specific insurance wants

 

[mdo1738]

That is not completely accurate.

In the Palmetto LCD (L38765) it states, "If there is an extended time, 2 years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."

Thus, if the patient had great pain relief for 2.5 years then returns with the exact same pain symptoms having returned with positive facet loading on examination, then i don't think there is a question as to the source of the pain and I go straight to RFA.

You’re reading it wrong. They are explicitly stating that MBB must be repeated if it’s one second beyond 2 years since the RFA. You may still be doing the RFAs but your facility isn’t getting paid for them. I had somebody just last week who had right side RFA 2 years and 2 days prior, and the other side ablated 1 year and 51 weeks prior. They denied ablation for both sides almost immediately, on the grounds of duration since last RFA. Patients are literally being penalized for getting too good of relief for too long from an RFA.

 

[knoxdoc]

Maybe we should merge this post with the recent one that read, "How to increase my procedure volume." 🙂

 

[SSdoc33]

Maybe we should merge this post with the recent one that read, "How to increase my procedure volume." 🙂

juice is still not worth the squeeze.

id much rather go straight to RF. i find it hard to get them thorugh the algorithma a second time. theoretically, that is 6-8 injections in 2 years. not to mention all the follow ups.

when i get a call from a patient who had an RF 2-3 years ago and they want another one..... its a deep sigh and a pissed off patient. especially when they didnt have to do this before.....

 

[geauxg8rs]

juice is still not worth the squeeze.

id much rather go straight to RF. i find it hard to get them thorugh the algorithma a second time. theoretically, that is 6-8 injections in 2 years. not to mention all the follow ups.

when i get a call from a patient who had an RF 2-3 years ago and they want another one..... its a deep sigh and a pissed off patient. especially when they didnt have to do this before.....

They can always pay cash

 

[Ducttape]

only 1 MBB is required in someone who had RFA>2 years ago.


the LCD in my area is not at restrictive, btw. Evicore states this:

 Note: When performing a repeat radiofrequency joint denervation/ablation at the same spinal level(s) as a prior successful denervation/ablation procedure, further diagnostic facet joint injections/medial branch blocks at that spinal level(s) are not necessary.

 

[SSdoc33]

only 1 MBB is required in someone who had RFA>2 years ago.


the LCD in my area is not at restrictive, btw. Evicore states this:

my LCD requires 2 new MBBs.

 

[buddababa]

my LCD requires 2 new MBBs.

same

 

[Laryngospasm]

For those of you enjoying the idea that you don’t have those same requirements as HOPD maybe you should ask for whom the bell tolls..

 

[ctts]

Apparently the LCD has been updated, and will be effective 7/7/24, and the word "or" has been taken out. So it now states:
"If there is an extended time, two years or more, since the last RFA and there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."
I think this language is better, and we can justify not repeating facet blocks, but would still be taking a chance with it....I guess we will know more in a few months how things are going with it.

 

[callmeanesthesia]

Apparently the LCD has been updated, and will be effective 7/7/24, and the word "or" has been taken out. So it now states:
"If there is an extended time, two years or more, since the last RFA and there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated."
I think this language is better, and we can justify not repeating facet blocks, but would still be taking a chance with it....I guess we will know more in a few months how things are going with it.

Yes, I’ve been meaning to post that on here. Several other updates as well. Most unfortunately, third level is now never allowed even in appeal. So we either make patients pay out of pocket for it or eat the cost.

 

[Agast]

Yes, I’ve been meaning to post that on here. Several other updates as well. Most unfortunately, third level is now never allowed even in appeal. So we either make patients pay out of pocket for it or eat the cost.

I eat the cost. It’s not very filling 🙁

I put it mentally towards my marketing budget since happy patients tell their PCPS and friends & family.

 

[Laryngospasm]

I’m just wondering when they will cut it down to two nerves..

 

[Ronin1]

Just had one denied for RFA. Previous RFA good for 24 months. Medicare requiring repeat MBBS.
Pts complaining. More wrvus for me.