Coventry-Aetna Anesthesia with Pain Injections and Amerigroup

Coventry / Aetna Payment Policy

Title:   Anesthesia Service for Pain Management and Back Injection Procedure

 

Coventry/Aetna will not allow payment for anesthesia services including MAC, with or without modifier QS, for the following pain management and back injection procedures:

20526, 20550, 20551, 20552, 20553, 20600, 20605, 20610, 27096, 36468-36469, 36470-36479, 62263, 62264, 62270, 62273, 62280, 62281, 62282, 62310, 62311, 62318, 62319, 62367, 62368, 64402, 64405, 64412, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64447, 64448, 64450, 64470, 64472, 64475, 64476, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64620, 64622, 64623, 64626, 64627, 64633, 64634, 64635, 64636, 64640, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T

When a provider (other than the one who performed the pain management or back injection procedure or vein procedure) provides this service, Coventry/Aetna will allow MAC for high-risk members only.  For purposes of this policy, high-risk is defined as:

• Children age 18 and under
• Adults age 65 and over
• Members meeting the criteria for billing of Physical Status modifiers P3, P4 or P5

 

 

Amerigroup Medical Policy

Title:   Percutaneous Neurolysis for Chronic Neck and Back Pain

CPT:  64633, 64634, 64635, 64636, 64640, 64999

 

Medically Necessary:

Initial radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3 thru C7-T1 vertebrae) or chronic lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae) is considered medically necessary when all of the following criteria are met:

1. No prior spinal fusion surgery in the vertebral level being treated; AND
2. Pain that is not radicular; AND
3. Low back (lumbosacral) or neck (cervical) pain, suggesting facet joint origin when evidenced by the absence of nerve root compression is documented in the medical record on history, physical and radiographic evaluations;
   AND
4. Pain that has failed to respond to 3 months of conservative therapy*; AND
5. A diagnostic, temporary block with local anesthetic of the facet nerve (medial branch block) or injection under fluoroscopic guidance into the facet joint has resulted in at least a 50% reduction in pain for the duration of the specific local anesthetic effect used [e.g., generally 3-4 hours for bupivacaine (Marcaine^®_, Sensorcaine^®₎ and 30 minutes to 1 hour for lidocaine (Xylocaine^®₎]. Note: a diagnostic, temporary block is not required for repeat RF at a previously treated site, if it has been less than one year since the last RF.

Repeat radiofrequency (RF) neurolysis for chronic cervical facet pain (C2-C3 thru C7-T1 vertebrae) or chronic lumbosacral facet pain (T12-L1 thru L5-S1 vertebrae) is considered medically necessary when:

1. The above criteria have been previously met to qualify for an initial treatment; AND
2. A minimum time of 6 months has elapsed since prior RF treatment (per side, per anatomical level of the spine).

*Note: Conservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual’s specific presentation, physical findings and imaging results.

Investigational and Not Medically Necessary:

1. Radiofrequency neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain for all uses that do not meet the criteria identified as medically necessary listed above, including but not limited to treatment of cervicogenic headache or thoracic facet pain.
2. Chemical neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
3. Pulsed radiofrequency denervation is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
4. Radiofrequency neurolysis for sacroiliac (SI) joint pain is considered investigational and not medically necessary.
5. Laser neurolysis is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
6. Cryodenervation (cryoablation) is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
7. Cooled radiofrequency denervation is considered investigational and not medically necessary for the treatment of chronic back pain, including but not limited to facet or sacroiliac (SI) joint pain.
8. Repeat radiofrequency neurolysis is considered investigational and not medically necessary when performed at the same anatomic site (side and spinal level) within 6 months of a prior treatment.

You can find the entire policy at:  https://medicalpolicies.amerigroup.com/medicalpolicies/policies/mp_pw_a050267.htm

 

 

Amerigroup Medical Policy

Title:   Peripheral Nerve Blocks for Treatment of Neuropathic Pain

CPT:  64415, 64417, 64447, 64450

 

Investigational and Not Medically Necessary:

Peripheral nerve blocks are considered investigational and not medically necessary for management of neuropathic pain, including but not limited to treatment of any of the following:

• Chemotherapy-induced peripheral neuropathy (CIPN);
• Chronic nonmalignant pain;
• Peripheral neuropathy (for example, diabetic neuropathy, HIV-related neuropathies, etc.);
• Trauma induced neuropathy.

You can find the entire policy at:  https://medicalpolicies.amerigroup.com/medicalpolicies/policies/mp_pw_c181196.htm

 

 

Amerigroup Medical Policy

Title:   Pain Management: Cervical, Thoracic & Lumbar Facet Injections

CPT:  64490-64492, 64493-64495, 0213T-0215T, 0216T-0218T

 

Medically Necessary:  Facet (cervical, thoracic, lumbar) injections are considered medically necessary when all of the criteria below are met:

A. The individual has back pain which has not responded to 3 months of appropriate conservative therapy*; AND

B. The pain is interfering with functional activities; AND

C. The pain is not radicular; AND

D. The pain is exacerbated by extension and prolonged standing/sitting and is relieved by rest; AND

E. The individual has not had a vertebral fusion at the levels proposed for treatment; AND

F. There is no unexplained neurological deficit; AND

G.There is no history of coagulopathy, systemic infection, local infection, or unstable medical conditions; AND

H. The facet block meets criteria for one of the injections below:

1. 1. The injection is being performed to diagnose the facet joint as the source of the individual’s pain;
      OR
   2. The injection is being performed to treat pain when all of the following criteria are met:
      1. A diagnostic block provided pain relief (at least 50% pain relief with the ability to perform previously painful maneuvers); AND
      2. A series of injections at that spinal region begin no sooner than one week after a successful diagnostic block; AND
      3. The injections continue no more often than every 2 months with a maximum of six injections per spinal region per year.

*Note: Conservative therapy consists of an appropriate combination of medication (e.g., NSAIDs, analgesics), physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions based on the individual’s specific presentation, physical findings and imaging results.

Note: If therapeutic facet injections are to be performed at a different spinal region, a positive diagnostic block is required in that region and the therapeutic frequency is limited to every 2 months for that region and therapeutic improvement is required in that region for additional facet injections.

Not Medically Necessary:  Facet injections of the spine are considered not medically necessary when the criteria specified above are not met, or when any of the following contraindications are present:

• For additional therapeutic facet injections in the absence of an improvement in pain or function;
• For therapeutic facet injections more frequently than every 2 months per spinal region;
• Therapeutic spinal facet injections more than 6 times per spinal region per year;
• In the presence of an unexplained neurological deficit.

You can find the entire policy at: https://medicalpolicies.amerigroup.com/medicalpolicies/guidelines/gl_pw_cl160721.htm

 

 

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Reasonable attempts have been made to be accurate.  However, medical billing, collections, coding and compliance are part science, part art, and even experts sometimes differ.  Neither Anesthesia Billing, Inc., the editors, publisher, contributors, or consultants warrant or guarantee the information contained will be applicable or appropriate in all situations.  For information specific to your practice, consult a qualified professional.

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Editor:  Philip Blann (pblann@anesthesiabilling.com).