CareSource is implementing a policy change that will require prior authorization for interventional pain management procedures. The change is effective July 1, 2011 and covers trigger point injections, facet joint/nerve injections, epidural injections, associated anesthesia and urine drug screening.
Trigger Point Injections
CareSource will reimburse up to a maximum of 8 trigger point injections per 12 month period regardless of location, rendering provider, or time interval between injections. Use of trigger point injections should only be considered in patients with a new incidence of pain and repeated only with documented positive results. Because of insufficient evidence to document the effectiveness of trigger point injections for chronic pain management, greater than 8 trigger point injections within a 12 month period will be considered not medically necessary.
Facet Joint and/or Facet Joint Nerve Injection
CareSource will consider Facet Joint and/or Facet Joint Nerve Injection medically necessary for evaluation of subacute non-radiating pain that is unresponsive within a reasonable period of time (usually no less than 8 weeks) to a well-managed course of conservative therapy and when the following criteria are met:
a. A thorough history and physical exam documents cause of the pain if known, duration of symptoms, severity, exacerbating factors, abnormal physical and diagnostic findings and prior conservative treatment measures
b. Documentation of associated medical and psychological disorders
c. Diagnostic studies including X-Rays and MRIs that have confirmed the diagnosis of facet arthropathy or degenerative disease of the spine
d. Facet joint and/or nerve blocks may be performed on the targeted joint itself, one joint above and one joint below on the same side per treatment session
e. If the patient does not show good response from the first block, additional procedures should not be considered. If the patient does show improvement with suitable pain relief from the first injection, a second and third block can be repeated as needed
f. No authorization is required for up to a total of 6 injections in a 12 month period, regardless of level(s). More than 6 injections by the same or multiple providers at a single or multiple level(s) within a 12 month period require prior authorization
Facet joint and/or nerve injections should be performed with imaging guidance. Image guidance and any injection of contrast are inclusive components of CPT Codes 64490-64495
g. Therapeutic facet joint injection is unproven for the treatment of chronic spinal pain and routine, periodic injections will not be authorized for management of chronic pain
Epidural Steroid Injections and Selective Transforaminal Epidural Injection
CareSource will consider Epidural Steroid Injections and Selective Transforaminal Epidural Injection (also known as selective nerve root blocks, SNRB) as clinically appropriate and medically necessary for diagnosis of acute and sub-acute sciatica or radicular pain of the low back or other levels that is unresponsive to a reasonable trial (usually not less than 8 weeks) of a well-managed course of conservative therapy and is caused by: Degenerative Vertebral Changes Spinal Stenosis Disc Herniation Post-laminectomy Syndrome with Radiculopathy Post-traumatic Neuropathy of the Spinal Roots
The following criteria must be met:
a. A thorough history and physical exam documenting cause of the pain if known, duration of symptoms, severity and exacerbating factors. Documentation also includes abnormal physical and diagnostic findings and prior conservative measures
b. Documentation of associated medical disorders and any relevant psychological considerations
c. Documentation of any diagnostic studies including X-Rays and MRIs that have confirmed the likelihood of degenerative disease or other abnormalities of the spine
Epidural Injections and selective nerve root blocks are considered medically necessary as part of a diagnostic evaluation for radicular pain when:
a. History and physical findings suggest radiculopathy but radiographic and neurodiagnostic studies are indeterminate,
b. Radiologic studies suggest a structural abnormality in proximity to a potentially affected nerve root, or
c. History and physical findings are suggestive for but not completely typical for nerve root involvement
Medical literature is inconclusive and controversial with regard to management of chronic
pain with epidural injections. CareSource considers epidural injections and SNRBs for management of chronic pain and all other indications except those listed above as investigational and not medically necessary.
Epidural injections and SNRBs are indicated for management of acute and subacute pain as part of a comprehensive pain management program. More than 3 epidural injections in a 12 month period require prior authorization.
Anesthesia for Facet Joint and Epidural Injections
Monitored anesthesia will be denied for trigger point injections, all facet joint or nerve injections and all epidural injections as not medically necessary.
a. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization, but services will be considered part of the procedure and are not eligible for additional reimbursement
b. If anesthesia or conscious sedation services are provided they must be delivered by CareSource contracted and credentialed providers, including anesthesiologists and CRNAs
Urine Drug Screening
a. Urine drug screening, utilizing point of service rapid test kits, will be reimbursed when medically appropriate and may be billed utilizing CPT 80101
b. Confirmatory reference laboratory testing does not require prior authorization for CareSource contracted labs and will be reimbursed when medically necessary
c. UDS must be specifically ordered by the attending physician and collected according to standard chain of command protocol. Reimbursement for urine drug screening that does not conform to acceptable protocol and medical necessity is subject to recovery following medical chart audit
d. CPT 80101 and other urine drug screening codes billed by non-participating labs will be denied
For more details, you can review the entire policy at http://www.caresource.com/en/media/global/PainManagementInterventionalProceduresPolicy.pdf.