Medical Necessity for Spinal Injections

on Tuesday, 19 June 2018. All News Items | MAC Reviews

Is It REALLY Necessary?

Sometimes I think I type “medical necessity” so much, that when I type an “m” my computer is automatically going to fill in those words. I also think those of us in healthcare hear the term “medical necessity” so much that we do not appreciate the real meaning. True, it is the conditions for coverage of many Medicare services as explained in Medicare manuals, regulations, and policies. But hopefully, Medicare bases those policies on a real and simple question – “is it really necessary?” As part of a retrospective review, that question can only be answered based on what is documented in the medical record. So proactively, when furnishing services, providers should be mindful of what questions must be asked, what the answers must be, and getting documentation of those answers in the medical record.

In this month’s Medicare Administrative Contractor (MAC) medical review updates (see table at the end of this article), CGS, the MAC for Jurisdiction 15, published results of findings from their Round One Targeted Probe and Educate (TPE) reviews. Those reviews included cataract removal, cardiac rehabilitation, and spinal injections. This Wednesday@One article takes a deeper look at spinal injections from Medicare’s perspective of ‘is it really necessary?’ based on CGS’s findings and their Local Coverage Determination (LCD) for Lumbar Epidural Steroid Injections (ESIs).

A Covered Condition

CGS’s LCD includes a listing of the conditions for which the injections are appropriate and beneficial to the patient. In assessing the patient’s need for an ESI procedure, a history and physical of the patient and preoperative imaging should support the medical necessity of the service. Imaging prior to the procedure should rule out red flag conditions, such as fractures or potential malignancies, and findings from radiology reports must be documented in the medical record.

Does It Matter?

If a condition does not have the potential to cause harm and is not interfering with the patient’s health or lifestyle, it does not have to be treated. For example, as we age and expose our skin to the sun, we often develop moles and freckles. The majority of moles and freckles do not have to be treated or removed unless they are or have the potential to be cancerous or affect us negatively in some way. Documentation to support the necessity of spinal injections should include discussion of the patient’s moderate to severe pain, including a numeric assessment of the patient’s pain (3 or greater per CGS’s LCD). Also, the pain must impair the patient’s activities of daily living (ADLs) and this too should be documented. This information is usually found in the pre-procedure examination, which includes a focused physical, musculoskeletal and neurological exam.

Would a Simpler Treatment Work?

The patient may not need a complex or invasive procedure if simpler treatments would resolve the problem. For spinal injections, the patient must generally try four weeks of non-surgical, non-injection care first. Documentation should clearly show what treatments were attempted, the time frame (at least 4 weeks), and that those treatments failed before the decision was made to utilize steroid injections.  There are some extenuating circumstances where 4 weeks of failed conservative treatment may not be required. If this is the case, the specific reasons for bypassing conservative treatments must be documented. Those conditions include moderate pain with significant functional loss, severe pain unresponsive to outpatient management, inability to tolerate conservative treatments due to existing medical conditions, and prior successful injections for the same condition.

Procedure Requirements

Per CGS’s LCD,

  • All elective ESIs should be done with fluoroscopy or CT image-guidance.
  • Contrast medium should be injected during epidural injection procedures unless the patient is at a high risk for an adverse event if contrast is used.
  • Films that adequately document final needle position and injectate flow must be retained and made available upon request.
  • 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.

Did It Work?

Subsequent injections are covered by Medicare if previous injections worked to relieve the patient’s pain and improve ADLs. Again, there must be documentation supporting this, specifically:

  • The response to the previous injection, including the percentage of relief provided,
  • The prior ESI was for the same specific condition,
  • The prior ESI was successful (effective response), and
  • Pain returned and is of such a severity that it impacts ADLs.

Although CGS is currently the only MAC reviewing spinal injections, several MACs have LCDs addressing this procedure. Providers need to review the LCD for their jurisdictions carefully, as different MACs may have different requirement specifics.

Policy #Policy NameMAC
L33906 Epidural First Coast JN Part B
L36920 Epidural Injections for Pain Management Novitas JH/JL Parts A/B
L34980 Lumbar Epidural Injections Noridian JF Parts A/B
L35937 Lumbar Epidural Injections NGS J6/JK Parts A/B
L34982 Lumbar Epidural Injections Noridian JE Parts A/B
L36521 Lumbar Epidural Injections WPS J5/J8 Parts A/B
L35148 Lumbar Epidural Steroid Injections Palmetto JJ/JM Part B
L34807 Lumbar Epidural Steroid Injections (ESI) CGS J15 Parts A/B

If you are not in the CGS jurisdiction or have not already had a Medicare review for spinal injections, now is a good time to review your documentation and answer the big question – “was it really necessary?”

All MAC Medical Review Updates from last month are summarized below:

MAC Medical Review Updates June 2018
MACService DescriptionService CodeDateError/Denial RateStatus
Novitas JH Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018 6/1/2018 Round 2
20% (JL)
Round 3 (June 2018)
Novitas JH Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018 6/8/2018   New (Round 1)
Novitas JH Denosumab J0897  6/1/2018   New (Round 1)
Novitas JH 3 Day Qualifying Hospital Stay   6/8/2018   New (Round 1)
Novitas JL Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018 6/1/2018 Round 2
Round 3 (June 2018)
Novitas JL Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018 6/8/2018   New (Round 1)
Novitas JL Denosumab J0897  6/1/2018   New (Round 1)
Novitas JL 3 Day Qualifying Hospital Stay   6/8/2018   New (Round 1)
CGS J15 Cataract Removal HCPCS 66984, 66983, 66982 5/29/2018 Round 1
19% - 23%
CGS J15 Review for Spinal Injections HCPCS 62323 5/29/2018 Round 1
CGS J15 Cardiac Rehab with continuous ECG Monitoring HCPCS 93798 5/29/2018 Round 1
18% - 53% 


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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