Casualty

Interventional pain management treatment frequently begins with a series of epidural and facet injections. These injections are performed in surgical centers and under anesthesia. Billing received is from three parties: the injecting physician, the anesthesiologist and the surgical center. Investigations and peer reviews have long focused on the first leg of the troika – the injecting physician – whether the patient had the requisite subjective complaints and response to treatment as being reported by the patient’s providers. Anesthesia has long been considered part and parcel of the injections – if the injection was considered medical necessary, anesthesia was medical necessary. However, this commonly held belief must be changed and the use of anesthesia for these procedures should go through the same investigational rigor by carrier’s SIU departments and independent peer review physicians.

CMS’s position is that the use of moderate or deep sedation, general anesthesia and monitored anesthesia care is “usually or rarely indicated” for epidural and facet injections and that in exceptional use and unique cases” there must be supporting documentation to establish the need for sedation for the specific patient. See LCD – Epidural Steroid Injections for Pain Management (L39054) and LCD – Facet Joint Interventions for Pain Management (L38803).

From an investigational standpoint, carriers should be reviewing the injecting physician’s records to determine if there is any basis provided for the need for anesthesia. Many providers simply denote that anesthesia would be utilized, without providing any patient-specific reason. A second scenario is where providers note that anesthesia is indicated because patients need to stay completely still. However, there is no evidence-based medical support for this position, and the American Society of Anesthesiologists (ASA) does not indicate that epidural and facet injections are procedures that require a patient to remain motionless for a prolonged period of time. See ASA’s Statement on Anesthetic Care During Interventional Pain Procedures for Adults.

The third and growing scenario that providers present are patients that have a needle phobia or anxiety. A review of these providers’ pre-certification requests reveals the same cookie-cutter language as to the patients’ fear of needles and anxiety over the procedures. This provides an opportunity for SIU. First, is this statement supported by the patient’s treatment history since the subject loss? Did the patient previously receive acupuncture, EMG/NCV testing or an in-office injection from another specialty? Moreover, recorded statements and Examinations Under Oath need to be utilized to confirm this basis. Are we asking our insureds/claimants whether they have a needle phobia? Did their physician ever discuss with them anesthesia for these procedures? Was the need for anesthesia presented as office policy and a requirement to receive these injections or was anesthesia based on patient specific needs? Accordingly, a simple review of the patient’s medical records and asking the right questions should be able to determine whether there are any misrepresentations being presented for the use of anesthesia.

Finally, our industry needs to expect more from our independent physicians when reviewing requests for these procedures. The epidural or facet injection is only one piece of the pie that needs to be reviewed and discussed during peer reviews/independent medical examinations. Our physicians need to opine as to the need for anesthesia and whether the precertification request provides any unique patient specific reasons to support anesthesia. The more in-depth peer reviews that discuss the need for every aspect of the injections – the need for the injection, the need for anesthesia, and the need for use of a surgical center will provide for stronger and a more diverse medical necessity defense during litigation. 

Ari is a shareholder in the Casualty Department focusing his practice on insurance fraud and Special Investigation Unit (SIU) litigation with particular emphasis on large loss fraud and medical provider fraud. His practice in the area of fraud investigation consists of assessing and analyzing fraud by both medical providers and falsified claims brought by his client’s insureds.  

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