Why MA Plans Denies Epidural Steroid Injection
Exceeds frequency limit (usually 3 per year per region)
Conservative therapy not documented
Prior injection did not provide documented relief
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
Building Your Medical Necessity Argument
Document radicular symptoms correlating with imaging
Note percentage and duration of relief from prior injection
Show failure of oral medications and PT
Reference imaging confirming nerve compression at the targeted level
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- ASIPP Guidelines for Interventional Pain Management
- NASS Coverage Recommendations for ESI
Relevant CPT Codes
Specialty: Pain Management / Anesthesiology
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