Sacral RF reimbursement

[Greenbayslacker]

I am a new pain doc so I apologize if this question is common knowledge.
After doing SI injections for patients that get >80% pain relief, the next step in my understanding would be sacral lateral branch RFA. However I am being told that no insurances will cover this, including Medicare. Is this factual, and if so, how do you guys do sacral RF? Or should I just continue doing standard SI injections? Thank you.

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[GlowInTheDark]

Apparently use AI Chatbot to write an appeal?

Otherwise cash for RFA or do SI injection every few months….until those aren’t covered.

 

[Orin]

I am a new pain doc so I apologize if this question is common knowledge.
After doing SI injections for patients that get >80% pain relief, the next step in my understanding would be sacral lateral branch RFA. However I am being told that no insurances will cover this, including Medicare. Is this factual, and if so, how do you guys do sacral RF? Or should I just continue doing standard SI injections? Thank you.

They're currently covered in Medicare LCDs. The proposal to take them out is pending.

Private payors are hit/miss, but generally do the block/IA injection and then ask whether the insurer would prefer fusion or ablation.

 

[drrosenrosen]

Not covered by Advantage plans(in my area at least) so pretty much just straight medicare. Private payors more miss than hit

 

[Ferrismonk]

One of the hardest things about Pain as a specialty is believing that you can help someone but no insurance agrees to pay. This is getting worse every year.

 

[Greenbayslacker]

They're currently covered in Medicare LCDs. The proposal to take them out is pending.

Private payors are hit/miss, but generally do the block/IA injection and then ask whether the insurer would prefer fusion or ablation.

Can you comment on the CMS guidelines I attached? That’s what my admin is using as justification to not do it.

 

[Ducttape]

yes, they are deemed experimental so they could get denied.

you should ask admin why you cannot just ask for prior authorization and then proceed if approved, and do not if denied.

 

[Greenbayslacker]

yes, they are deemed experimental so they could get denied.

you should ask admin why you cannot just ask for prior authorization and then proceed if approved, and do not if denied.

for aetna, they say "does not need prior auth" and then next line "may not be reimbursed" 🤣

 

[Agast]

Medicare has to have a specific policy addressing the procedure in order to have the advantage/replacement plans cover it. The absence of local coverage determination allows them to deny the procedure, even if Medicare will reimburse the code. It’s a loophole.