Facet procedures
What pain severity is required for a medial branch block?
Moderate to severe
A patient has right low back pain with radiation into the right lateral thigh and dorsum of the foot. MRI demonstrates multilevel neural foraminal stenosis at every level with no spinal canal stenosis noted. Which procedure would you order?
A. Bilateral L5-S1 TFESI
B. Right L5-S1 TFESI
C. Bilateral L4-5, L5-S1 TFESI
D. Right L4-5, L5-S1 TFESI
B. Right L5-S1 TFESI. L5 dermatomal distribution. If spinal canal stenosis at L4-5 and neural foraminal stenosis at L5-S1, then could justify a right L4-5, L5-S1 TFESI.
Which procedures require a formal psych clearance?
A. sprint
B. intracept
C. Mild
A. Sprint.
Intracept doesn't need a formal eval but does need documentation taht this was assessed in clinic.
A patient is determined to be a low risk patient on chronic narcotic pain medications. How often can you check a urine drug screen?
Twice yearly
How long does pain need to be present to justify a lumbar facet procedure?
At least 3 months. AND must demonstrate failure of conservative treatmetns or failure to tolerate.
How long must pain be present to justify a TFESI?
4 weeks
How long does a patient need to have back pain for before an intracept can be ordered?
6 months
A patient is determined to be a moderate risk patient on chronic narcotic pain medication. How often can you check a UDS?
Quarterly. Or once every 3 months.
Can I do a lumbar MBB if I have an untreated lumbar radiculopathy?
No. Treat the radiculopathy or radicular symptoms FIRST, then pursue treatment for axial symptoms as appropriate with MBB.
A patient with lumbar radiculitis is found to have multilevel foraminal stenosis throughout her lumbar spine. She has her first ever lumbar TFESI at L5-S1 on 1/1/2026 and experiences 50% pain relief for two weeks only. Pain is back to baseline and is radicular. What is the best next step?
A. Order another TFESI at another level, immediately
B. Order another TFESI at another level, at 3 months
C. No further TFESIs are indicated since she did not have 50% relief for 3 months
A. Ok to order repeat TFESI at another level, as early as two weeks if most recent TFESI was their first ever. Otherwise, have to wait 3 months prior to repeat TFESI in the same body region (cervicothoracic, lumbar).
How many total vertebral levels can be treated with intracept throughout a patient's lifetime?
4 total levels. And no more than two levels at a time during one session.
A patient is determined to be a high risk on chronic narcotic pain medications. How often can we check a urine drug screen through medicare?
Monthly
Mr. Jones has a cervical RFA on 1/1/2025, then on 7/1/2025 he has a thoracic RFA. How soon until the cervical RFA can be repeated?
1/2/2026. Only two RFAs will be reimbursed in a rolling twelve month period for a body region. Cervicothoracic is considered one region. Lumbar is considered one region.
Which is not indicated for TFESI?
A. Radiculopathy
B. Acute herpes zoster pain
C. Post laminectomy syndrome
D. Axial low back pain from a disc bulge
D. No TFESIs for axial symptoms. TFESIs are indicated for radicular symptoms or acute zoster symptoms
"ESIs to treat non-specific low back pain (LBP), axial spine pain, complex regional pain syndrome, widespread diffuse pain, pain from neuropathy from other causes, or cervicogenic headaches are considered investigational and therefore are not considered medically reasonable and necessary."
A patient undergoes a lumbar SCS trial. Which option needs to be met to justify a lumbar SCS perm?
A. 50% reduction in target pain and function improvement
B. 50% reduction in analgesics and function improvement
Either 50% reduction in pain or 50% reduction in pain meds
A opioid risk tool is used before starting Mr. Jones on hydrocodone. He scores a 4. What risk category is he in based solely of the ORT?
Moderate risk. So Quarterly urine drug testing if basing off ORT alone.
Mr. Z had a BL L234 RFA on 8/4/2024. He had over 50% relief for 6 months. Then the pain returned and he had repeat BL L234 RFA on 2/2025. It helped but not as much as previous ablations, reporting 40% relief. What is a reasonable next step?
Update MRI, re-examine, consider BVN if modic changes, Sprint PNS if pain still thought to be facet mediated. If another level is considered such as L345 instead of L234. Please remember four MBBs are approved per rolling twelve months per body region, and two RFAs only per rolling twelve months per body region.
A patient has a BL L5-S1 TFESI on 1/1/2025 with over 50% relief for 3 months. Then 8/2/2025 she has a repeat LTFESI with 50% relief for 3 months. You see her on 1/12/2026 and order a repeat LTFESI. What is specifically needed to meet CMS criteria?
A. Discuss and document steroid burden, and send note to PCP
B. Document the patient does not desire surgery or is high risk for surgery
C. Perform the LTFESI in conjunction with conservative treatments
D. All of the above
"The ESIs should be performed in conjunction with conservative treatments."
"Patients should be part of an active rehabilitation program, home exercise program or functional restoration program."
"It generally would not be considered medically reasonable and necessary for treatment with ESI to extend beyond 12 months.Frequent continuation of ESIs over 12 months may trigger a focused medical review. Use beyond twelve months requires the following:
How many SCS trials can be performed per body region per patient lifetime?
2 per body region per lifetime.
Noridian will reimburse for placement of a maximum of 2 leads or 16 “contacts,” and for 2 SCS trials per anatomic spinal region per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology). More than 2 SCS trials per anatomic spinal region per patient per lifetime is not considered reasonable and necessary.
If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure.
A patient is on oxycodone 5mg TID prn. She also takes tizanidine 2mg BID and gabapentin 600mg TID. Upon review of the PMP she takes xanax as prescribed by her PCP. Her ORT score is 2. How often should you check a urine drug screen?
Ultimately it is up to the discretion of the provider. BZDs and opioids is a risky combination. Also gabapentinoids, muscle relaxers, and opioids increases risk. ***