Wiki Facets and rf's

[LORIN830]

I have two questions:

1. Our LCD for Medicare for Facets states "providing more than three levels of facet joint blocks to a patient on the same day is not considered medically necessary. Treatment is in excess of three levels unless documentation supports the medical necessity". Sometimes our docs do 4 levels. Medicare is paying for qty of 3 and denying the 4th for not medically necessary. My question is can we appeal with the medical record, and if so what should be documented as to the reason for 4 levels? Or is there not point and we should just not do more than 3 levels?

2. Medicare is also denying some of our RF's for the same reason. THe LCD for that states no more than 3 levels is medically necessary. For example: Md documented "Radiofrequency Neurolysis of the medial branch of the primary dorsal ramus innervating the right lumbar facets at L2-3, L3-4, L4-5. We billed 64622(x1) and 64623 (x3). The LCD states they pay for no more than 3 levels, but RF is not billed per spinal level it's by nerve root. I am thouroughly confused. Help!

Thanks!

 

[NIENAJADLY]

facet vs. rf

We have the same policy limitations and have found that, even on appeal with records, we get no more than the maximum listed in the policy. In fact, we've even had our carrier deny the entire claim, not just the extra level that they don't want to pay for. We were able to send a corrected claim and have it reprocessed but then you need to send notes, etc.

We've advised our docs of this and they are trying to keep just to what is allowed by the policy to avoid any denials and reviews.

Hope this helps.
Kellie