Indications and Limitations of Coverage and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Patient controlled analgesia - The postoperative insertion of an intravenous catheter and preprogramming of a patient-activated delivery system to control the first several days of postoperative pain.
Epidural anesthesia - The insertion of a catheter allowing access to the epidural space for the purpose of injecting anesthetic or narcotic medication.
Trigger point injections
- Trigger point injection refers to the injection of local anesthetics or anti-inflammatory medications into myofascial trigger points. Trigger points are self-sustaining irritative foci that occur in skeletal muscle in response to strain, as well as mechanical overload phenomena. These trigger points produce a referred pain pattern characteristic for the individual involved muscle.
- Trigger point injections are an integral part of comprehensive pain management, and may be used concurrently in support of other conservative modalities. Conservative therapy may include analgesics, passive physical therapy, ultrasound, range of motion, chiropractic intervention (within the defined limits of the Medicare benefit) and active exercises. Additionally, trigger point injections may be indicated when joint movement is mechanically limited, as in the case of the coccygeus muscle. The diagnosis of trigger points requires a detailed history and thorough physical examination.
- The following clinical features are consistently present and are helpful in making the diagnosis:
- History of onset of the painful condition and its presumed cause (e.g., injury or sprain).
- Distribution pattern of pain consistent with the referral pattern of trigger points.
- Range of motion restriction.
- Muscular deconditioning in the affected area.
- Focal tenderness of a trigger point.
- Palpable taut band of muscle in which trigger point is located.
- Local taut response to snapping palpation.
- Reproduction of referred pain pattern upon stimulation of trigger point.
- The goal is to treat the cause of pain, not just the symptoms. With this intent, it is expected that trigger point injections may be performed as frequently as a monthly interval from the time of onset of illness or injury for the first three sets of injections of a treatment course, and as frequently as every two months thereafter for an additional three sets of injections. At that point, the patient should be re-evaluated regarding the etiology of the complaint, and the available treatment options reconsidered. Medicare will consider payment for additional trigger point injections upon review.
Nerve blocks - Nerve blocks are temporary interruptions of conduction in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions. Somatic and sympathetic nerves may be injected. In the diagnostic mode, this procedure can help differentiate a nerve that is a pathway for the conduction of pain impulses, to determine the type of nerve conducting the pain, to distinguish between central and peripheral origins of pain, and to evaluate the potential benefit of other neurolytic procedures or surgical lysis of a nerve. In a therapeutic mode, the procedure may be used for the treatment of painful conditions that respond to this modality (i.e., celiac block for the treatment of pain related to GI neoplasms), or to prevent pain following procedures.
Limitations Endoscopic lysis of adhesions by use of an epiduroscope is a relatively new technique in the treatment of back pain. Approved by the Food and Drug Administration (FDA) in 1996 and marketed by several centers, there is insufficient evidence in peer-reviewed medical literature to support its use at this time.
Pain examination under anesthesia, a two-step procedure to reproduce pain before and after the administration of IV Pentothal, is considered non-covered as it has not been shown to be safe or effective at present. Medicare will consider re-review at a later time if additional peer-reviewed literature is presented.
Pharmacologic challenges for sympathetically maintained pain using IV medications such as lidocaine, phentolamine, carbamazepine or imipramine are considered to be investigational and currently not supported by peer-reviewed literature.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section
13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical
practice for the diagnosis or treatment of the patient's
condition or to improve the function of a malformed body
member.
- Furnished in a setting appropriate to the patient's medical needs
and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient's medical needs.
- At least as beneficial as an existing and available medically
appropriate alternative.
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for pain management services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for pain management services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding pain management services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- Medicare Benefit Policy Manual - Pub. 100-02: Chapters 1 and 15.
- Medicare National Coverage Determinations Manual - Pub. 100-03.
- Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.
- Social Security Act (Title XVIII) Standard References, Sections:
- 1862(a)(1)(A) Medically Reasonable & Necessary.
- 1862(a)(1)(D) Investigational or Experimental.
- 1862(a)(7) Screening (Routine Physical Checkups).
- 1833(e) Incomplete Claim.
Jurisdiction "H" Notice:
Jurisdiction "H" comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 - 11/19/2012); and, is a consolidation of the previous legacy contractors' policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination.
| ST | Legacy A
Contractor
&
Contract Number | Legacy B
Contractor
&
Contract Number | J "H" MAC A
Contractor
&
Contract Number | J "H" MAC B
Contractor
&
Contract Number | J "H"
Effective
Date |
|---|
| AR | | PBSI: 00520 (J7) | | Novitas: 07102 | 08/13/12 |
| LA | | PBSI: 00528 (J7) | | Novitas: 07202 | 08/13/12 |
| AR | PBSI: 00020 (J7) | | Novitas: 07101 | | 08/20/12 |
| LA | PBSI: 00233 (J7) | | Novitas: 07201 | | 08/20/12 |
| MS | PBSI: 00233 (J7) | | Novitas: 07301 | | 08/20/12 |
| MS | | Cahaba: 00512 (J7) | | Novitas: 07302 | 10/22/12 |
J 4
States | Trailblazer: 04901 | | Novitas: 04911 | | 10/29/12 |
| CO | Trailblazer: 04101 | | Novitas: 04111 | | 10/29/12 |
| NM | Trailblazer: 04201 | | Novitas: 04211 | | 10/29/12 |
| OK | Trailblazer: 04301 | | Novitas: 04311 | | 10/29/12 |
| TX | Trailblazer: 04401 | | Novitas: 04411 | | 10/29/12 |
| CO | | Trailblazer: 04102 | | Novitas: 04112 | 11/19/12 |
| NM | | Trailblazer: 04202 | | Novitas: 04212 | 11/19/12 |
| OK | | Trailblazer: 04302 | | Novitas: 04312 | 11/19/12 |
| TX | | Trailblazer: 04402 | | Novitas: 04412 | 11/19/12 |
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