FUTURE Local Coverage Determination (LCD): Pain Management (L35033) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Please note: Future Effective Date. Contractor Information Contractor Name Novitas Solutions, Inc. Contract Number 04412 Contract Type A and B MAC Jurisdiction J - H LCD Information Document Information L35033 Original ICD-9 LCD ID L32702 LCD Title Pain Management LCD ID AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Jurisdiction Texas Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2015 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A Printed on 9/21/2015. Page 1 of 8
UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. 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. Coverage Guidance Coverage Indications, Limitations, 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. 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 Printed on 9/21/2015. Page 2 of 8
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. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient Printed on 9/21/2015. Page 3 of 8
071x Clinic - Rural Health 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 083x Ambulatory Surgery Center 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance. 0360 Operating Room Services - General Classification 0450 Emergency Room - General Classification 049X Ambulatory Surgical Care - General Classification 050X Outpatient Services - General Classification 051X Clinic - General Classification 052X Free-Standing Clinic - General Classification 0761 Specialty Services - Treatment Room CPT/HCPCS Codes Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. Group 1 Codes: 62263 Epidural lysis mult sessions 62264 Epidural lysis on single day 62280 Treat spinal cord lesion 62281 Treat spinal cord lesion 62282 Treat spinal canal lesion 62310 Inject spine cerv/thoracic 62311 Inject spine lumbar/sacral 62318 Inject spine w/cath crv/thrc 62319 Inject spine w/cath lmb/scrl 64400 N block inj trigeminal 64402 N block inj facial 64405 N block inj occipital 64408 N block inj vagus 64410 N block inj phrenic 64412 N block inj spinal accessor 64413 N block inj cervical plexus 64415 N block inj brachial plexus 64417 N block inj axillary 64418 N block inj suprascapular 64420 N block inj intercost sng 64421 N block inj intercost mlt 64425 N block inj ilio-ing/hypogi 64430 N block inj pudendal 64435 N block inj paracervical 64445 N block inj sciatic sng 64450 N block other peripheral 64483 Inj foramen epidural l/s 64484 Inj foramen epidural add-on Printed on 9/21/2015. Page 4 of 8
64505 N block spenopalatine gangl 64508 N block carotid sinus s/p 64510 N block stellate ganglion 64520 N block lumbar/thoracic 64530 N block inj celiac pelus 64633 Destroy cerv/thor facet jnt 64634 Destroy c/th facet jnt addl 64635 Destroy lumb/sac facet jnt 64636 Destroy l/s facet jnt addl 77003 Fluoroguide for spine inject ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Note: Medicare is only establishing limited coverage for CPT codes 64633, 64634, 64635 and 64636 as listed above. All other CPT codes included in this policy will not be subject to limited coverage at this time because there are numerous reasonable and necessary conditions that warrant their application. An appropriate ICD-10-CM code must be submitted with each claim, coded to the highest level of specificity for that date of service. Covered for: Group 1 Codes: ICD-10 Codes Description M43.00 Spondylolysis, site unspecified M43.01 Spondylolysis, occipito-atlanto-axial region M43.02 Spondylolysis, cervical region M43.03 Spondylolysis, cervicothoracic region M43.04 Spondylolysis, thoracic region M43.05 Spondylolysis, thoracolumbar region M43.06 Spondylolysis, lumbar region M43.07 Spondylolysis, lumbosacral region M43.08 Spondylolysis, sacral and sacrococcygeal region M43.09 Spondylolysis, multiple sites in spine M43.10 Spondylolisthesis, site unspecified M43.11 Spondylolisthesis, occipito-atlanto-axial region M43.12 Spondylolisthesis, cervical region M43.13 Spondylolisthesis, cervicothoracic region M43.14 Spondylolisthesis, thoracic region M43.15 Spondylolisthesis, thoracolumbar region M43.16 Spondylolisthesis, lumbar region M43.17 Spondylolisthesis, lumbosacral region M43.18 Spondylolisthesis, sacral and sacrococcygeal region M43.19 Spondylolisthesis, multiple sites in spine M47.10 Other spondylosis with myelopathy, site unspecified M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region M47.12 Other spondylosis with myelopathy, cervical region M47.13 Other spondylosis with myelopathy, cervicothoracic region M47.14 Other spondylosis with myelopathy, thoracic region M47.15 Other spondylosis with myelopathy, thoracolumbar region M47.16 Other spondylosis with myelopathy, lumbar region M47.20 Other spondylosis with radiculopathy, site unspecified M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region M47.22 Other spondylosis with radiculopathy, cervical region M47.23 Other spondylosis with radiculopathy, cervicothoracic region M47.24 Other spondylosis with radiculopathy, thoracic region M47.25 Other spondylosis with radiculopathy, thoracolumbar region Printed on 9/21/2015. Page 5 of 8
ICD-10 Codes Description M47.26 Other spondylosis with radiculopathy, lumbar region M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region M47.891 Other spondylosis, occipito-atlanto-axial region M47.892 Other spondylosis, cervical region M47.893 Other spondylosis, cervicothoracic region M47.894 Other spondylosis, thoracic region M47.895 Other spondylosis, thoracolumbar region M47.896 Other spondylosis, lumbar region M47.897 Other spondylosis, lumbosacral region M47.898 Other spondylosis, sacral and sacrococcygeal region M47.899 Other spondylosis, site unspecified M47.9 Spondylosis, unspecified M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture M48.51XA Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture M50.00 Cervical disc disorder with myelopathy, unspecified cervical region M50.01 Cervical disc disorder with myelopathy, high cervical region M50.02 Cervical disc disorder with myelopathy, mid-cervical region M50.03 Cervical disc disorder with myelopathy, cervicothoracic region M50.30 Other cervical disc degeneration, unspecified cervical region M50.31 Other cervical disc degeneration, high cervical region M50.32 Other cervical disc degeneration, mid-cervical region M50.33 Other cervical disc degeneration, cervicothoracic region M51.04 Intervertebral disc disorders with myelopathy, thoracic region M51.05 Intervertebral disc disorders with myelopathy, thoracolumbar region M51.06 Intervertebral disc disorders with myelopathy, lumbar region M51.34 Other intervertebral disc degeneration, thoracic region M51.35 Other intervertebral disc degeneration, thoracolumbar region M51.36 Other intervertebral disc degeneration, lumbar region M51.37 Other intervertebral disc degeneration, lumbosacral region M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture M96.1 Postlaminectomy syndrome, not elsewhere classified ICD-10 Codes that DO NOT Support Medical Necessity N/A ICD-10 Additional Information General Information Printed on 9/21/2015. Page 6 of 8
Other Information Associated Information Refer to LCD L35010, Trigger Point Injections, for guidance specific to trigger point injections. Documentation Requirements Documentation supporting medical necessity should be legible, maintained in the patient s medical record and made available to Medicare upon request. Utilization Guidelines Notice: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. Sources of Information and Basis for Decision Other Contractor Local Coverage Determinations Pain Management, TrailBlazer LCD, (00400) L17454, (00900) L17444. Paravertebral Facet Joint, TrailBlazer LCD, (00400) L14129, (00900) L14138. Paravertebral Facet Joint Block and Facet Joint Denervation, Noridian Administrative Services, LLC LCD, (CO) L23747. Blocks and Destruction of Somatic and Sympathetic Nerves, Noridian Administrative Services, LLC LCD, (CO) L23692. Injection of Spinal Canal, Noridian Administrative Services, LLC LCD, (CO) L16553. Trigger Point Injections, Noridian Administrative Services, LLC LCD, (CO) L23773. Paravertebral Facet Nerve Denervation, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L12131. Paravertebral Facet Joint Nerve Block, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L8151. Intercostal Nerve Blocks/Neurolysis, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L16131. Steroid Injections, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L11682 and L11835. Local Injections for Trigger Points, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L11677 and L11783. Epidural Injections, Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L13444 and L13457. Novitas Solutions, Inc. JH Local Coverage Determination (LCD) Consolidation Narrative Justification Most Clinically Appropriate LCD LCDs Compared: L32122, Surgery: Injections of the Spinal Canal, Cahaba, MS - B L26743, Pain Management, TrailBlazer, CO, NM, OK, TX A/B L8097, Local Injections for Trigger Points, Pinnacle, AR - B L31008, Epidural Injections, Pinnacle, LA, MS - A L13483, Epidural Injections, Pinnacle, LA - B L21874, Epidural Injections, Pinnacle, AR - A L13423, Epidural Injections, Pinnacle, AR B L31034, Local Injections for Trigger Points, Pinnacle, LA, MS A L11955, Local Injections for Trigger Points, Pinnacle, LA B L18767, Local Injections for Trigger Points, Pinnacle, AR A L30647, Surgery: Trigger Point Injections, Cahaba, MS - B Printed on 9/21/2015. Page 7 of 8
CMD Rationale: LCD L26743 from TrailBlazer is the most comprehensive of all the LCDs reviewed given the significant overlap between LCDs. L26743 includes trigger point injections, epidural injections, nerve blocks, and other miscellaneous spinal injections covered in the other LCDs. L26743 has a well written Indications/Limitations sections and the most comprehensive list of CPT codes. The Sources of Information and Basis for Decision is not present in L26743 as TrailBlazer adopted the LCD from another LCD during the J4 transition. L26743 is the most clinically appropriate LCD. Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision Revision History History Date Number 10/01/2015 R1 Associated Documents Attachments N/A Related Local Coverage Documents N/A Related National Coverage Documents N/A Revision History Explanation LCD was revised to reflect ICD-10 CM Annual Changes. ICD- 10 diagnosis codes M50.01, M50.31, and M84.58XA have undergone code descriptor changes. These changes are reflected in the policy. Reason(s) for Change Revisions Due To ICD-10-CM Code Changes Public Version(s) Updated on 07/31/2014 with effective dates 10/01/2015 - N/A Updated on 04/02/2014 with effective dates 10/01/2015 - N/A Keywords N/A Read the LCD Disclaimer Printed on 9/21/2015. Page 8 of 8