HomePopularMedicare Guidelines For Pain Management Injections 2021

Medicare Guidelines For Pain Management Injections 2021

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B Coverage For Surgery

Updates to L39054 Epidural Steroid Injections for Pain Management

Part B pays for the majority of services received while in the hospital for surgery. This means that Part B covers the surgery itself, lab work, some medications, and more. The costs for surgery under Part B is just like most other Part B services. Beneficiaries can expect to pay a deductible, copay, and/or coinsurance for their surgery.

Barricaid Annular Closure Device

An assessment of annulus fibrosus repair after lumbar discectomy by the Ludwig Boltzmann Institute for Heatlh Technology Assessment found that the closure of anular defects after discectomy using the Barricaid device could be a meaningful intervention for a selected group of patients with a large anular defect to prevent reherniations and reoperations. However, a significant number of patients experienced problems with device integrity over a period of two years. In addition, these results are based on a few studies with a high risk of bias and published long-term results beyond a period of two years are missing. Similar results in terms of clinical effectiveness and safety were obtained for the Xclose system. However, only results from a single randomized controlled trial with a high risk of bias are available.

The authors stated that this study had 2 main drawbacks. First, the 2-year follow-up, in which 70 % or fewer patients were actually followed-up, was short and limited the veracity with which conclusions could be applied in the long-term. However, it provided important early information regarding the stability and survivability of the device. These findings mirrored those of other investigators who examined this ACD and found that the device ensured maintenance of favorable clinical scores and lower rates of re-herniation. Second, the low sample size of this cohort limited the ability to extrapolate results to larger populations.

Proposed Medicare Changes Affect Prescription Pain Medications

Coverage for high doses of opioids will change for all Medicare beneficiaries under the Medicare Plan D proposed 2019 regulations. The U.S. government is concerned about the opioid epidemic and is committed to being proactive to combat the overuse and abuse of these medications. However, many individuals with chronic pain conditions have responsibly used opioid therapy for many years to treat their pain and are concerned that their treatment regimen will be affected by these proposed regulations.

Proposed regulations on prescribed opioid dosages

Under the proposed Medicare Part D new regulations, the maximum opioid dosage would be 90 MME per day. Therefore, the covered ceiling dosage of hydrocodone would be 90 mg per day, and the ceiling dosage for oxycodone would be 60 mg per day. The new proposed regulations also include a hard edit rule which would require pharmacists to talk with the prescribing doctor and insurance company in the event that a higher dosage of an opioid is required. The Medicare-approved insurance company would make the final decision on this request. While the hard edit regulation is being considered for approval, CMS could approve a temporary seven-day supply of opioids with a new prescription from a physician. However, this seven-day supply would be a one-time approval.

Proposed regulations on medication combinations

Chronic pain community concerns

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Does Medicare Cover Cortisone Injections

  • Original Medicare and Medicare Advantage plans can cover cortisone injections for pain relief and arthritis. Learn more about the costs, eligibility requirements and other Medicare coverage details for cortisone shots.

Around a quarter of all Americans aged 65 and older have arthritis, according to the Centers for Disease Control and Prevention .

Doctors use cortisone injections, a drug used to treat inflammation, as an effective treatment option for arthritic conditions. Cortisone can help people with rheumatoid arthritis, reactive arthritis, and osteoarthritis. These injections can also relieve other painful conditions like back pain, tendinitis, and gout.

If your doctor recommends cortisone shots, its useful to understand how Medicare covers cortisone injections.

Esis: Patient Selection Is Key


Kim Mauer, MD, Medical Director of the Comprehensive Pain Clinic at Oregon Health and Science University, agrees that ESI treatment has come a long way in recent years. Imaging has improved and now we can do more precise injections in less time, she told PPM.

Selecting the appropriate patients for this therapy is crucial, however, and there are many nuances to the process.

Bridger Bach, MD, clinical fellow in pain medicine at the Vanderbilt University Medical Center in Tennessee, spoke about candidacy for ESIs. He explained, for instance, that patients who have progressive, incurable conditions such as spinal stenosis with significant comorbidities such as renal disease or heart disease would be poor candidates for long-term treatment with NSAIDs. This same group of patients may also be poor candidates for opioid therapy because of liver or pulmonary disease or past opioid use disorder. As a result, ESIs may be the best treatment choice for them.

In addition, older patients are often on multiple medications, such as benzodiazepines or muscle relaxants, that put them at risk for respiratory events. According to Dr. Bach, This might be a good group for epidural steroid injections as a good addition to their analgesic regime because it helps them achieve their goals of pain reduction and functionality while being a relatively safe type of treatment for them.

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How Much Does Medicare Pay For Pain Management

There isnt one standardized way in which Medicare covers pain management. Chronic pain can be caused by several different conditions or injuries that require varying types of treatment.

Some treatment options related to chronic pain that Medicare may help cover include, but arent limited to:

  • Physical therapy
  • Pain medication

Does Medicare Cover Pain Management

Pain management includes a wide spectrum of treatments and techniques that are used to help control and reduce chronic pain due to illness or injury. Coverage for certain forms of treatment may be covered under Medicare Part B while others may require a Medicare Part D prescription drug plan.

Common Types of Pain Management

Effectively treating chronic pain requires a careful evaluation of a patients needs and the underlying causes of their pain. In many cases, a combination of treatment types will be prescribed or suggested.

Developing a plan for pain management may involve input from several health care professionals, especially when prescription medication or medical procedures are required.

Medicare Coverage for Pain Management

Recipients who receive qualifying pain management treatment through outpatient services may have coverage under Medicare Part B. This may include certain types of occupational or physical therapy. Depression or substance abuse screening and individual or group therapy sessions can also fall under Part B coverage terms. These services may require out-of-pocket payments due to the deductible, copayment or coinsurance cost-sharing rules.

Medicare Part D prescription drug plans may cover many of the medications necessary for pain management, but these plans are offered through private insurers and each provider determines which medications are included in their coverage.

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Medicare Coverage For Conditions Of Lower Back Requiring Pain Management Treatments

Below, well go over some spine-related ailments the details of coverage for each treatment.


Only those feeling pain starting from the sacroiliac joint, or SIJ, have true sciatica. Those suffering from sciatica can obtain coverage for lumbar epidural steroid injections.

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Disc Herniation

Sometimes, surgery, known as a discectomy, is performed to fix a herniated disc. But, Medicare doesnt cover discectomies because patients can often get relief for a herniated disc through non-surgical approaches. These avenues for relief include exercise, physical therapy, massage, and pain medication. Epidural steroid injections can also help.

Lumbar Stenosis

Medicare doesnt consider the treatment of percutaneous image-guided lumbar decompression , so there is no coverage.

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Facet Joint Arthropathy

If medically necessary, epidural steroid injections for this condition obtain coverage from Medicare. Physical therapy may also help with this condition but might not get coverage unless a doctor refers you.

Lumbar Spondylolisthesis

Medicare doesnt cover lumbar artificial disc replacement surgery. Alternative treatments are pain management medications and physical therapy. The latter have coverage when a doctor refers you to help get back on your feet.

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Correction: Pain Management And Injection Prior Authorization

Medicare Coverage and Payment of Virtual Services

In the August edition of the Network Bulletin, we informed you that starting Nov. 1, 2021, we are expanding our prior authorization requirements for UnitedHealthcare commercial plans including All Savers, River Valley, Neighborhood Health Partnership, UnitedHealthcare West and MidAtlantic Health.

Please note thatCPT® codes 62292, 64454, 64480, 64491, 64492, 64494, 64496, 64634 and 64636, listed under pain management and injections, will NOT be subject to prior authorization requirements on Nov. 1, 2021. Also note, codes 64491, 64492, 64494 and 64495 are addressed in a separate announcement impacting Arizona, effective Feb. 1, 2021.


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Pain Management Coding Updates And New Guidelines For 2022

Posted by 1st Providers Choice on April 21, 2022

Managing pain can sometimes be difficult for pain specialists, especially satisfying patients with unique needs. They use several approaches, including interventions, noninvasive techniques, and counseling to help patients manage their pain effectively to improve their quality of life.

Therefore, providers should assign valid codes on claims to describe the patients condition in multimodal pain management programs. However, the constant changes in billing rules and codes make this a tedious task.

Check out these pain management coding updates and new guidelines for 2022 as well as other codes currently in use.

The Deuk Laser Disc Repair

Deuk Laser Disc Repair® is a surgical technique that incorporates 3 distinct procedures including a selective partial discectomy, foraminoplasty, and annular debridement. All of the results of full-length articles in peer-reviewed journals of the Deuk Laser Disc Repair® are from a single investigator group. These studies did not include internal comparison groups of patients undergoing ACDF.

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Cooled Radiofrequency Ablation For Facet Denervation

Furthermore, an UpToDate review on Subacute and chronic low back pain: Nonsurgical interventional treatment suggested not performing radiofrequency denervation for chronic LBP due to available data that are inconsistent and the authors suggested that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term however, there does not appear to be clear long-term benefit. Also, there is no mention of cooled RFA for treatment of back pain.

Medicare Part D Pain Management And The Opioid Crisis

Promoting Appropriate Coverage Criteria for Epidural Procedures for ...

Medicare Part D prescription drug plans may impose certain restrictions on their coverage of prescription opioids for pain management.

While the drugs including Vicodin, OxyContin, morphine, codeine and fentanyl may be effective at treating severe pain, many people have developed an addiction to the drugs.

Medicare reacted to the opioid epidemic of the 2010s by introducing additional opioid safety protocols for Medicare Part D plans. These included safety alerts at pharmacies for Part D enrollees who were filling their first opioid prescription and for those receiving high doses of the drugs.

Medicare Part D Coverage Rules for Prescription Opioid Benefits

  • May require prior authorization from your plan administrator before the prescription is covered.
  • Safety checks at the pharmacy.
  • Limits on how many doses you can have filled at a time.
  • Step therapy to safely step down and off the prescription.

The expanded rules seek to identify potential safety risks while not interfering with people who need access to prescription opioids due to a medical necessity, according to the U.S. Centers for Medicare & Medicaid Services.

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How Much Does Medicare Cover For Pain Management

There are several factors that may influence Medicares coverage of pain management treatments. There are three tiers of Medicare coverage:

  • Part A: hospital insurance
  • Part B: medical insurance
  • Part D: drug coverage

Your deductible, coinsurance, and premiums are dependant on what level of coverage you have. Coverage for your chronic pain treatment is also dependant on what level of coverage you have. For example, Part D will likely cover prescription medication, Part B may cover physical therapy and other medically necessary pain relief procedures. If you require surgery, Part A may cover your hospital stay.

The best way to find out what your deductible, premium, or coinsurance payments may cost is to contact Medicare directly.

OmniSpine Pain Management does accept Medicare, but the exact treatments covered by Medicare depends on your level of coverage.

Medicare Coverage For Esis

AAPM closed their letter by stating, The MPW societies would welcome the opportunity to again work with the Medicare Administrative Contractors to revise the coverage criteria included in the LCDs to ensure appropriate access to epidural injections for Medicare patients. Meanwhile clinicians should be aware that the decision to recommend ESI can be a tricky one. Dr. Mauer recommends consulting a pain specialist when in doubt.


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Total Facet Arthroplasty System

The Total Facet Arthroplasty System is a non-fusion spinal implant indicated for treatment of moderate-to-severe spinal stenosis. The TFAS replaces the diseased facets following surgical removal.

The TFAS clinical trial is a multi-center, prospective, randomized controlled clinical trial comparing the safety and effectiveness of the TFAS to spinal fusion surgery in the treatment of moderate-to-severe degenerative lumbar spinal stenosis. However, the status of this clinical trial is unknown .

License For Use Of Physicians Current Procedural Terminology Fourth Edition

Physician and NPP Education: 2021 CPT Medicare E/M documentation guidelines for outpatient services

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You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services . You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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Medicare Coverage For Sij Injections

Sacroiliac joint injections are also known as SIJ injections. They are therapeutic injections that treat pain and inflammation. The practitioner injects numbing medication and cortisone into the sacroiliac joint, which is located by the buttocks. If doctors consider this injection necessary for pain relief, it will get coverage from Medicare.

Medicare Part D Coverage

Medicare Part D covers prescription drugs. If you need a prescription for cortisone tablets, your Part D plan may cover them.

You can receive this coverage as a standalone Part D plan with Original Medicare or as part of a Medicare Advantage plan that includes prescription drug coverage. A licensed insurance agent can help you compare Medicare Advantage plans where you live and find a plan that covers prescription drugs as well as Part B-covered cortisone injections.

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Who Is A Candidate For Radiofrequency Ablation

Because radiofrequency ablation is minimally invasive and has a low risk of side effects, itâs typically considered safe for most individuals. In particular, people experiencing the following medical conditions may benefit from radiofrequency ablation:

  • Arthritis
  • Whiplash and other orthopedic injuries
  • Pain associated with spine surgery
  • Chronic pain of the neck, back, hip or pelvic
  • Tumors, non-cancerous thyroid nodules and other growths

If youre on blood thinners or you havent responded well to local anesthetic blocks, you may not be a good candidate for RFA.

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Next Steps In Interventional Pain Medicine

Promote Appropriate Coverage of Epidural Injections

AAPM closed their letter by stating, The MPW societies would welcome the opportunity to again work with the Medicare Administrative Contractors to revise the coverage criteria included in the LCDs to ensure appropriate access to epidural injections for Medicare patients.

Meanwhile, clinicians should be aware that the decision to recommend ESI can be a tricky one. For those in primary care, Dr. Mauer recommends consulting a pain specialist when in doubt.

1. AAPM, et al, Letter to CGS Administrators. February 4, 2021.

2. FDA. Safety Communication: FDA Requires Label Changes to Warm of Rare but Serious Neurologic Problems after Epidural Corticosteroid Injections for Pain. April 23, 2014.


Far Lateral Microendoscopic Diskectomy

Extra-foraminal lumbar disc herniations at the lumbo-sacral junction are an uncommon cause of L5 radiculopathy. The surgical anatomy of the extra-foraminal space at L5 to S1 is challenging for the various open surgical approaches that have been described for ELDHs in general. Reports specifically describing minimally invasive surgical approaches to lumbo-sacral ELDHs are lacking.

Pirris and colleagues noted that surgical access to ELDHs is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5 to S1 in particular remains a challenge. The authors reported on a small series of patients and provided a video presentation of a minimally invasive approach to L5 to S1 ELDHs utilizing a tubular retractor with microscopic visualization.

How Can Cano Health Help With Chronic Pain Management

Cano Health has a highly experienced arthritis and chronic pain management team, which specializes in the diagnosis and treatment of conditions such as arthritis, rheumatic, connective tissue diseases, and osteoporosis.

Living with chronic pain is difficult on the body, but it also is difficult for our mental and emotional states. It can become even more challenging to manage pain. Our experts can help so you can live your life to the fullest.

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