SCS Peer-to-peer

[paintrain]

I have a P2P with an MD from a commercial insurance agency. They initially denied SCS trial for a patient. The patient has a plethora of pain issues most notably low back pain, lumbar spondy, radic, numbness/tingling in feet, neuropathy, to name a few. They've failed conservative therapy including ESI, RFA, PT, meds. Told not to be a surgical candidate. This insurance has listed indications for SCS as: Failed Back Surgery, CRPS or Critical Limb Ischemia. They don't really fit nicely into any of these. In reality, can I expect them to approve SCS for a non-approved indication if I argue for it? Or are P2P's only to see if a patient does actually fit into one of their approved categories? For example, maybe I should argue during the P2P that they do have early signs of CRPS although that wasn't the initial working diagnosis that was documented when we submitted for auth. In other words, what's the best way to get this approved?

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[lobelsteve]

I have a P2P with an MD from a commercial insurance agency. They initially denied SCS trial for a patient. The patient has a plethora of pain issues most notably low back pain, lumbar spondy, radic, numbness/tingling in feet, neuropathy, to name a few. They've failed conservative therapy including ESI, RFA, PT, meds. Told not to be a surgical candidate. This insurance has listed indications for SCS as: Failed Back Surgery, CRPS or Critical Limb Ischemia. They don't really fit nicely into any of these. In reality, can I expect them to approve SCS for a non-approved indication if I argue for it? Or are P2P's only to see if a patient does actually fit into one of their approved categories? For example, maybe I should argue during the P2P that they do have early signs of CRPS although that wasn't the initial working diagnosis that was documented when we submitted for auth. In other words, what's the best way to get this approved?

Yup, just lie to them and commit fraud. Or better yet, pick a different patient. It is why a lot of what we do does not seem to work. Wrong patient selection.

 

[SSdoc33]

I have a P2P with an MD from a commercial insurance agency. They initially denied SCS trial for a patient. The patient has a plethora of pain issues most notably low back pain, lumbar spondy, radic, numbness/tingling in feet, neuropathy, to name a few. They've failed conservative therapy including ESI, RFA, PT, meds. Told not to be a surgical candidate. This insurance has listed indications for SCS as: Failed Back Surgery, CRPS or Critical Limb Ischemia. They don't really fit nicely into any of these. In reality, can I expect them to approve SCS for a non-approved indication if I argue for it? Or are P2P's only to see if a patient does actually fit into one of their approved categories? For example, maybe I should argue during the P2P that they do have early signs of CRPS although that wasn't the initial working diagnosis that was documented when we submitted for auth. In other words, what's the best way to get this approved?

this patient doesnt sound like a good candidate for SCS. SCS is not the final default option for all "pain patients"

 

[Orin]

In my experience, it depends on your peer and the documentation.

SCS can be a reasonable option for chronic localized neuropathic pain states when you have exhausted conservative options. The insurance provider peer can definitely argue that it is not appropriate and possibly provide other options.

This sounds like a salvage attempt for a marginal case, and is higher risk for failure than a simple FBSS/radic.

 

[paintrain]

Seems the longer you are a member here, the more jaded and unhelpful you are. There are multiple RCTs for neuropathy, low back pain, leg pain for SCS. So not sure why lobolsteve is getting his panties in a bunch. Maybe you don't keep up with literature. Anyway, @SSdoc33 and @Orin thank you for your advice.

 

[SSdoc33]

Seems the longer you are a member here, the more jaded and unhelpful you are. There are multiple RCTs for neuropathy, low back pain, leg pain for SCS. So not sure why lobolsteve is getting his panties in a bunch. Maybe you don't keep up with literature. Anyway, @SSdoc33 and @Orin thank you for your advice.

i think thats a fair assessment for pretty much everyone except ducttape. im not sure how he fends off the cynicism.

 

[lobelsteve]

Seems the longer you are a member here, the more jaded and unhelpful you are. There are multiple RCTs for neuropathy, low back pain, leg pain for SCS. So not sure why lobolsteve is getting his panties in a bunch. Maybe you don't keep up with literature. Anyway, @SSdoc33 and @Orin thank you for your advice.

You state you wish to lie to get a procedure approved for no adequate indication. Your so called literature is terrible for LbP and neuropathy.

Working on reviewing SIS best practices for SCS. You are not doing an ethical job and this will damage our field. And I’m not wearing any panties.

 

[Ducttape]

If he is young, don’t even bother. There is most likely some psychopathology if your tests are all normal and he has failed everything.


If this is like an elderly/ 80+ year old with neuropathy, talk to the Peer to peer about a trial for palliative pain management.

 

[SommeRiver]

Since when is persistent radiculitis not a viable Dx code?

 

[Agast]

I have a P2P with an MD from a commercial insurance agency. They initially denied SCS trial for a patient. The patient has a plethora of pain issues most notably low back pain, lumbar spondy, radic, numbness/tingling in feet, neuropathy, to name a few..

He has radicular pain? If he has been told by surgeons they will not operate on him (old, too sick for spine surgery) then it's not quite fair to say he needs a laminectomy first in order to have a stim trial. I submitted the note from a spine surgeon stating they would not do the surgery and recommended SCS instead, and that overturned a denial. Anyway it's a trial, he should be able to test drive it and see for himself if it makes an obvious difference.

On a side note, I definitely think it works better for postlaminectomy pain vs prelaminectomy but no one wants to operate on an 89-year-old...

 

[Agast]

Also, if high index of suspicion send your patient to a cardiologist. I have had 3 patients now with significant arterial stenosis causing ischemic claudication that was misdiagnosed by PCP as radicular pain because their backs hurt.

 

[thecentral09]

Also, if high index of suspicion send your patient to a cardiologist. I have had 3 patients now with significant arterial stenosis causing ischemic claudication that was misdiagnosed by PCP as radicular pain because their backs hurt.

Agree with this, but we are all doctors who can order ABI’s and do a standard vascular exam ourselves. I probably order ABIs weekly

 

[callmeanesthesia]

Agree with this, but we are all doctors who can order ABI’s and do a standard vascular exam ourselves. I probably order ABIs weekly

Where do you send people for an ABI? I’ve had a few patients where that would be handy.

 

[painfree23]

Where do you send people for an ABI? I’ve had a few patients where that would be handy.

I’ve sent 3 hoping for bad results and all came back normal lol

 

[SommeRiver]

I’ve sent 3 hoping for bad results and all came back normal lol

#metoo

 

[lobelsteve]

I've had dozens of severe disease but only occasionally will VS operate.

 

[NOSfan]

I have a P2P with an MD from a commercial insurance agency. They initially denied SCS trial for a patient. The patient has a plethora of pain issues most notably low back pain, lumbar spondy, radic.....In other words, what's the best way to get this approved?

Inform them SCS is FDA approved for limb pain.

Additionally, even though not MC, check your CMS LCD. Our area now allows for Lumbar Radiculopathy to be a covered entity and does not require previous surgery. Perhaps this should help with approval as you already indicate they are diagnosed with such. Finally, your patient seems to fit a diagnosis of Chronic Pain Syndrome, which with Lumbar Radiculopathy should be covered.

Good luck.

 

[painfree23]

Inform them SCS is FDA approved for limb pain.

Additionally, even though not MC, check your CMS LCD. Our area now allows for Lumbar Radiculopathy to be a covered entity and does not require previous surgery. Perhaps this should help with approval as you already indicate they are diagnosed with such. Finally, your patient seems to fit a diagnosis of Chronic Pain Syndrome, which with Lumbar Radiculopathy should be covered.

Good luck.

Same thing here ...denied because didn’t meet CRPS failed back or vascular issues in legs. I even had emg findings of a radic but denied by the high school educated person on the other end. Then did a peer to peer and they said doesn’t meet one of those 3 diagnosis so not covered.

 

[lobelsteve]

Same thing here ...denied because didn’t meet CRPS failed back or vascular issues in legs. I even had emg findings of a radic but denied by the high school educated person on the other end. Then did a peer to peer and they said doesn’t meet one of those 3 diagnosis so not covered.

What were the emg findings?

 

[BobBarker]

Lumbosacral plexopathy!

 

[SommeRiver]

Poor recruitment

 

[painfree23]

What were the emg findings?

I’m anesthesia so unfortunately rely a lot on the impression but it stated : “Likely L5 radiculopathy”

 

[lobelsteve]

I’m anesthesia so unfortunately rely a lot on the impression but it stated : “Likely L5 radiculopathy”

2 muscles, different peripheral nerves, common nerve root with PSW/Fibs 2+ in both or it ain't a radic. I almost never see a properly done EMG and conclusions are rarely in line with findings.

 

[Taus]

Agree.... but why mandate 2+ on the fibs/sharp waves? My understanding is no difference between 1-4+ on spontaneous activity.

 

[lobelsteve]

Depends on the myographer. Between noise and findings, it is subjective. 2+ means more likely findings. YMMV.