Knowledge Base Article

The expression 'the writing is on the wall' is used whenever an inevitable result or imminent danger has become apparent. It comes from the biblical story in the book of Daniel of God writing a warning to King Belshazzar on the wall. The Phrase Finder website

Local Coverage Determinations (LCDs) are determinations by Medicare Administrative Contractors (MACs) as to whether or not a particular item or service is covered in accordance with section 1862(a)(1)(A) of the Social Security Act. LCDs may expand on the requirements of a National Coverage Determination or address certain services that do not have an NCD but for which the MAC has concerns about the efficacy and necessity of the service. In other words, the MAC may need to describe the particular requirements that must be met and documented in the medical record to support the medical necessity of the service. Sometimes you can tell a lot about the potential risk of non-compliance simply by the number of MACs that have a coverage policy for a particular service – sort of “the writing on the wall” for providers. One such service is facet joint injections – all 12 MAC jurisdictions have an LCD describing coverage requirements for this service.

The reasons for this widespread concern about facet injections can be found in the LCD Introduction paragraph from the Palmetto LCD:

“Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.”

This basically says that the efficacy of this procedure is not proven and there are serious risks so, in order for facet injections to be covered, providers must have documented proof of the need and outcomes that show the treatment works. There is variation between the policies, so be sure to read the LCD for your jurisdiction and follow the requirements of that policy. However, it is often helpful to review other policies for a better understanding of the procedure and potential concerns.

Demonstrating Need

Almost all of the policies require an initial evaluation that includes history and an appropriately focused musculoskeletal and neurological physical examination, as well as pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain. Be sure to include in this documentation:

• Documentation of pain – A pain severity description (mild, moderate, or severe) or a numeric pain scale rating (1-10) is generally required – check your local LCD to determine which specific pain description the policy requires. For example, Palmetto requires the pain to be moderate or severe while the Novitas policy requires average pain levels of 6 or greater. Also address the duration of the pain (usually 3 months), and make sure it complies with your jurisdiction’s LCD requirements.
• The pain results in a functional impairment – if the pain is bad enough to justify the procedure, it is bad enough to cause a functional impairment – difficulty with walking, bending, lifting, or some other specific activity of daily living.
• Conservative treatments have been tried and failed – be specific on what was tried – drugs, therapy, etc. If there are contraindications that prevented trying some conservative treatments, document that also.
• The pain is facet in nature. Some policies require that the pain be predominately axial and not associated with radiculopathy or neurogenic claudication or non-facet pathology.

Demonstrating Efficacy

Because of the concerns noted above about the risks and efficacy of facet joint injections, diagnostic injections must be done first to show the patient will receive relief.

From the Palmetto LCD:

• Dual medial branch blocks (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.
• A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain ≥ 50% as evidenced by documented functional improvement, increased range of motion, a decreased requirement for pain medications and duration of relief is consistent with the agent employed.
• Intra-articular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions.

Again, confirm the requirements for diagnostic injections and the required outcome for your local LCD.

In addition, there are requirements for the percent and duration of pain relief from therapeutic injections that must be met before Medicare will cover a repeat injection if needed.

Procedure Requirements

A dated, signed and legible procedure note must describe the details of the facet injection, including “a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations, as well as pre and post-procedural pain assessments.”

Other requirements from the Palmetto LCD include:

• Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance.
• Hard or digital copy images documenting the needle position and contrast medium flow must be retained and submitted if requested.
• Limits on the volume and dosage of drugs.
• Limits on the number of injections in a specified time frame.
• Performed by appropriately trained providers whose qualifications meet the requirements of the LCD.

You may also want to read a prior Wednesday@One article that discussed the findings of a Noridian medical review of facet joint injections. The Noridian articles referenced in the W@1 article are no longer available, but the article includes details of Noridian’s education.

As you can see, there are a lot of requirements and supporting documentation necessary to meet the facet joint injection LCDs. Would your facility’s medical records hold up to the scrutiny of a Medicare reviewer? If not, you may be at risk of claim denials or recoupments should you be reviewed. My recommendation is to be proactive by reading your MAC’s LCD and then making sure you follow the requirements and document appropriately. Seven MACs for 12 Jurisdictions with eight Facet Joint LCDs (Noridian assigns separate LCD ID numbers to each of their 2 jurisdictions) – the writing is on the wall.