BCBS of TN - SI Joint Inj "INVESTIGATIONAL" eff. 12/10/2011

Investigational? My Sacroiliac!!

By Leslie Johnson, CPC

I don’t often write pieces like this because this is a “facts only” type of website, allowing for visitors to leave their own voices/opinions to the facts. Otherwise, it would be all about Leslie, not about our industry. You can thank a couple of on-the-ball ladies from TN who attended sessions at the CodingCon Conference, in Orlando, FL this week and brought this news forward.

Effective 12/10/2011, BCBS of Tennessee, has suddenly decided that SI Joint Injections and Arthrography are no longer payable:

“POLICY

• Arthrography of the sacroiliac joint is considered investigational.

• Injection into the sacroiliac joint for diagnostic or therapeutic purposes is considered investigational.”

http://www.bcbst.com/UpcomingMPs/Topics_12-1-11/Sacroiliac_Joint_Arthrography_and_Injection_policy.pdf

(if they remove this URL, I do have a copy of it that I’ll include when it gets uploaded)

At first glance, it appears to be a policy built around various authorities on the internet that claim that such procedures are investigational/experimental. BCBS wants to be pro-active regarding the current state of healthcare and pay only for those procedures not considered harmful or not considered effective. It makes a lot of sense, doesn’t it?

One of the sources of information that BCBS of TN to back up their new assertion that SI Joint Injections & SI Joint Arthrography is investigational comes here: http://www.guideline.gov/popups/printView.aspx?id=23845 ; purportedly from this: “Guideline Title

Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. “

Advice to the wise: READ IT, because it appears that BCBS of TN hasn’t or they’ve twisted the information & want everyone to think something different.

Scroll down to the “Recommendations” header & review what’s written – Did someone miss something? Feel free to respond in the comments section because clearly, an actual dialogue is needed. Below is an excerpt of this documentation under the “Recommendations” header.

“Major Recommendations

I. Patient Evaluation

· All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.

· History:

· A pain history should include a general medical history with emphasis on the chronology and symptomatology of the presenting complaints.

· A history of current illness should include information about the onset, quality, intensity, distribution, duration, course, and sensory and affective components of the pain and details about exacerbating and relieving factors.

· Additional symptoms (e.g., motor, sensory, and autonomic changes) should be noted.

· Information regarding previous diagnostic tests, results of previous therapies, and current therapies should be reviewed by the physician.

· In addition to a history of current illness, the history should include (1) a review of available records, (2) medical history, (3) surgical history, (4) social history including substance use or misuse, (5) family history, (6) history of allergies, (7) current medications including use or misuse, and ( review of systems.

· The causes as well as the effects of pain (e.g., physical deconditioning, change in occupational status, and psychosocial dysfunction) and the impact of previous treatment( should be evaluated and documented.

· Physical examination: The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation, with attention to other systems as indicated.

· Psychosocial evaluation: The psychosocial evaluation should include information about the presence of psychological symptoms (e.g., anxiety, depression, or anger), psychiatric disorders, personality traits or states, and coping mechanisms.

· An assessment should be made of the impact of chronic pain on a patient's ability to perform activities of daily living.

· An evaluation of the influence of pain and treatment on mood, ability to sleep, addictive or aberrant behavior, and interpersonal relationships should be performed.

· Evidence of family, vocational, or legal issues and involvement of rehabilitation agencies should be noted.

· The expectations of the patient, significant others, employer, attorney, and other agencies may also be considered.

· Interventional diagnostic procedures: Appropriate diagnostic procedures may be conducted as part of a patient's evaluation, based on a patient's clinical presentation.

· The choice of an interventional diagnostic procedure (e.g., selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, and provocative discography) should be based on the patient's specific history and physical examination and anticipated course of treatment.

· Interventional diagnostic procedures should be performed with appropriate image guidance.

· Diagnostic medial branch blocks or facet joint injections may be considered for patients with suspected facet-mediated pain to screen for subsequent therapeutic procedures.

· Diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of patients with suspected sacroiliac joint pain.

· Diagnostic selective nerve root blocks may be considered to further evaluate the anatomic level of radicular pain.

· The use of sympathetic blocks may be considered to support the diagnosis of sympathetically maintained pain.

· They should not be used to predict the outcome of surgical, chemical, or radiofrequency sympathectomy.

· Peripheral blocks may be considered to assist in the diagnosis of pain in a specific peripheral nerve distribution.

· Provocative discography may be considered for the evaluation of selected patients with suspected discogenic pain.

· Provocative discography should not be used for the routine evaluation of the patient with chronic nonspecific back pain.

· Findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide the foundation for an individualized treatment plan focused on the optimization of the risk–benefit ratio with an appropriate progression of treatment from a lesser to greater degree of invasiveness.

· Whenever possible, direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care management.

Another reference source used for this policy is this: http://www.guideline.gov/popups/printView.aspx?id=12540

From: “Guideline Title

Low back disorders.

Bibliographic Source(

Final advice to Tennessee Pain Management Specialists: SCREAM and APPEAL! Use their own documents, highlighting the above referenced information, with any appeals if denials ensue because of erroneous interpretation to the above. Physicians, heal thyself and speak out.

Comments are welcome and encouraged.

L J