Medicare contractors mull restricting coverage for key image-guided pain procedure
Medicare Administrative Contractors are considering whether to label a key image-guided procedure for chronic pain as medically unnecessary.
Five of the seven MACs recently released proposed local coverage determinations, pertaining to peripheral nerve blocks. Such treatment typically involves using ultrasound or X-ray guidance to insert a needle near a nerve to inject an anesthetic or corticosteroid.
MACs are now seeking public comment on whether the federal payment program for seniors should not cover this interventional service. The American College of Radiology highlighted this issue on Oct. 8. It noted that the outcome “could significantly affect coverage for peripheral nerve ablation procedures, many of which now are deemed not medically necessary under the proposals.”
“ACR members are encouraged to review the proposed [local coverage determinations] and related billing/coding articles and submit evidence-based comments challenging the coverage decisions,” the college said in a news update. “Interventional radiologists should act quickly; comment deadlines begin Nov. 8.”
MACs mulling this issue include CGS Administrators, National Government Services Inc., Noridian Healthcare Solutions, Palmetto GBA, and WPS Insurance Corp. (with the latter’s comment deadline falling on Nov. 22). In coverage documents, contractors contend the use of sedation or general anesthesia for these procedures is “usually unnecessary or rarely indicated.”
“Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient,” the proposed LCD notes. “[Peripheral nerve blocks] and procedures to treat complex regional pain syndrome, widespread diffuse pain, (i.e., fibromyalgia, myofascial pain, and chronic pain syndrome), or systemic polyneuropathies are investigational and therefore are not considered medically reasonable and necessary,” it added.
This is not the first time radiologists have had to fight to defend payment for peripheral nerve blocks. In May, the Society of Interventional Radiology and other trade groups wrote to Humana, urging the commercial insurer to modify its policies related to the procedure. And last year, SIR and others implored Cigna to reverse its decision deeming peripheral nerve blocks as unwarranted.
“Peripheral nerve stimulation consistently results in improvement in pain, reduced disability, lower opioid use and improvement in quality of life for people affected by chronic pain,” societies representing radiologists, anesthesiologists, neurologists, urologists and other specialists wrote to Cigna. “By dismissing [peripheral nerve stimulation] as ‘not medically necessary,’ Cigna denies patients access to a treatment modality that has been recommended in treatment guidelines created by physician societies.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.