Lumbar Epidural Injections – Noridian Medicare
As we suspected last year, refining coverage guidelines for Lumbar Epidural Injections now require the use of fluoroscopic or CT guided imaging.
Some highlights from Noridian Medicare (California), effective October 1, 2015 include:
Coverage Indications, Limitations, and/or Medical Necessity
Introduction:
For purposes of this policy, a “session” is defined as all epidural or spinal procedures performed on a single calendar day.
Lumbar epidural injections are generally performed to treat pain arising from spinal nerve roots. These procedures may be performed via three distinct techniques, each of which involves introducing a needle into the epidural space by a different route of entry. These are termed the interlaminar, caudal, and transforaminal approaches. The procedures involve the injection of a solution containing local anesthetic with or without corticosteroids.
Indications
1. Pain associated with
Herpes Zoster and/or
Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve and/or
Neurogenic claudication and/or
Low back pain, NPRS ≥ 3/10 (moderate to severe pain) associated with significant impairment of activities of daily living (ADLs) and one of the following:
a. substantial imaging abnormalityies such as a central disc herniation,
b. severe degenerative disc disease or central spinal stenosis.
2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes appropriate oral medication(s) and physical therapy to the extent tolerated…
• Exceptions to the 4 week wait may include:
a. pain from Herpes Zoster
b. at least moderate pain with significant functional loss
at work or home.
c. severe pain unresponsive to outpatient medical management.
d. inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s)
e. prior successful injections for same specific condition with relief of at least 3 months’ duration.
Procedure Requirements
1. An appropriately comprehensive evaluation of all potential contributing pain generators and treatment in accordance with an established and documented treatment plan.
2. Plain films to rule out red flag conditions may be appropriate if potential issues of trauma, osteomyelitis or malignancy are a concern.
3. Real-time imaging guidance, fluoroscopy or computed tomography, with the use of injectable radio-opaque contrast material is required for all steroid injections and all transforaminal injections. Its use is urged but not required for other epidural injections.
4. Contrast medium should be injected during epidural injection procedures unless patient has contraindication to injection. The reasons for not using contrast must be documented in the procedure report.
5. Films that adequately document final needle position and injectate flow must be retained and made available upon request.
6. For each session, no more than 80mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, 15 mg of dexamethasone or equivalent corticosteroid dosing may be used
7. When a diagnostic spinal nerve block is performed, post-block assessment of percentage pain relief must be documented.
8. Levels per session:
a. No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally)
b. One caudal or lumbar interlaminar injection per session and not in conjunction with a lumbar transforaminal injection.
9.Frequency:
a. No more than 3 epidurals may be performed in a 6-month period of time.
b. No more than 6 epidural injection sessions (therapeutic epidurals and/or diagnostic transforaminal injections) may be performed in a 12-month period of time regardless of the number of levels involved.
c. If a prior epidural provided no relief, a second epidural is allowed following reassessment of the patient and injection technique.
10. Local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.
Provider Qualifications
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) states that “reasonable and necessary” services are “ordered and/or furnished by qualified personnel.” Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
Patient safety and quality of care mandate that healthcare professionals who perform Epidural Steroid Injections are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. (At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities).
Limitations
1. For a patient with low back pain only, a simple disc bulge or annular tear/fissure is insufficient to justify performance of an epidural.
2. Patient must not have major risk factors for spinal cancer (e.g., LBP with fever) or, if cancer is present, but the pain is clearly unrelated, an epidural may be indicated if one of the “Indications” previously listed is present.
3. A co-existing medical or other condition that precludes the safe performance of the procedure precludes coverage of the procedure, e.g., new onset of LBP with fever, risk factors for, or signs of, cauda equina syndrome, rapidly progressing (or other) neurological deficits.
4. Numbness and/or weakness without paresthesiae/dysesthesiae or pain precludes coverage.
5. There is no role for “series of three” epidurals. Response to each epidural should be determined prior to determining the value of a repeat epidural and the specific methods used for subsequent epidurals.
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The complete LCD L34982 can be found at: https://med.noridianmedicare.com/web/jeb/policies/lcd/active
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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