Interventional Pain Management (IPM) prior authorization program
Customize your policy alerts
Sign up for all marylandphysicianscarempc policy alerts
Know when marylandphysicianscarempc releases new policies or updates existing guidance.
Monitor payer policy activity
Governs prior authorization requirements and administrative processes for non-emergent outpatient interventional pain management procedures for Maryland Physicians Care members; affects ordering and rendering providers who perform specified IPM procedures.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization Criteria
Covered when ALL of the following are met
Only outpatient procedures require prior authorization through NIA
These procedure categories are managed under the program
Typical ordering specialties for IPM requests
Upload to RadMD preferred; fax option available
Interventional pain management (IPM) procedures included in this program are limited to outpatient, non-emergent services. IPM procedures performed in the Emergency Room, as part of inpatient care, or during a larger surgical/intraoperative procedure are excluded from the NIA prior authorization program and do not require authorization through NIA.
An authorization number is not a guarantee of payment. Authorizations are issued based on medical necessity and remain contingent on member eligibility and benefits at claim adjudication; benefits limitations or coordination of benefits may affect payment. Retrospective review of completed procedures is possible to determine whether urgent or emergent circumstances justified lack of prior authorization and whether services meet medical necessity when the claim is processed.
Provider Actions and Authorization Requirements
Prior authorization required for listed outpatient IPM procedures
Prior authorization must be obtained before scheduling or performing outpatient, non-emergent interventional pain management (IPM) procedures. This program applies only to outpatient services and does not include procedures performed in the Emergency Room, as part of inpatient care, or during a larger surgical/intraoperative procedure. The affected procedure categories are: spinal epidural injections; paravertebral facet joint injections or blocks; paravertebral facet joint denervation (radiofrequency neurolysis); and sacroiliac joint injections.
- Obtain prior authorization through NIA before scheduling/performing the service.
- Use RadMD (preferred) or NIA call center for submission.
- Program scope limited to outpatient, non-emergent IPM procedures; ER, inpatient, and intraoperative procedures are excluded.
Document prior conservative therapy, duration, and results
Include documentation of all conservative treatment modalities tried, with the duration of each modality and the outcome or clinical response. Examples listed by the program include physical therapy, chiropractic/osteopathic manipulation, hot pads/massage/ice packs, and medications.
- List each modality attempted (e.g., physical therapy, manipulation, heat/ice, massage, medication).
- Specify start/end dates or total duration for each modality.
- State the clinical outcome or effectiveness of each modality.
Include required clinical documentation on the prior authorization request
Provide complete clinical information on the prior authorization request: ordering physician name and office phone, member name and ID, requested procedure, facility where service will be performed, anticipated date of service, date of pain onset, physician exam findings and symptoms, clinical diagnosis, dates/results of prior IPM procedures, diagnostic imaging results when available, and conservative treatment details (modalities, duration, results). Upload supporting clinical notes and imaging to RadMD (preferred) or fax using the NIA fax coversheet when requested.
- Ordering physician name and office phone number
- Member name and ID number
- Requested procedure and facility/location
- Anticipated date of service
- Date of pain onset, exam findings, and clinical diagnosis
- Dates and results of prior IPM procedures and diagnostic imaging
- Conservative treatment modalities completed, duration, and outcomes
- Upload clinical notes/imaging to RadMD or fax with NIA coversheet if requested
Denial, re-review, and appeal process — timelines and submission
If a request is denied, a re-review may be initiated by uploading or faxing additional clinical information using the case-specific fax coversheet; the re-review must be started within 2 business days from the date of denial and before filing a formal appeal. Peer-to-peer review is available by calling NIA's call center.
- Initiate re-review by uploading documents to RadMD or faxing with the case-specific NIA fax coversheet.
- Re-review must be initiated within 2 business days of the denial date and prior to a formal appeal.
- Providers may request peer-to-peer review via NIA (call 1-800-424-4836).
Conservative Treatment Documentation Requirements
Documentation required as part of prior authorization request
Documentation required as part of prior authorization request
Fields marked with * in source are required on the request
Include physical exam findings applicable to the requested services
Provide dates and outcomes of previous interventions
Upload imaging results to RadMD or fax when requested
Document modalities attempted, duration, and outcomes
Upload to RadMD preferred; if unable to upload, fax using the NIA fax coversheet
Imaging and Diagnostic Requirements
Provide diagnostic imaging results when requested
When available, include diagnostic imaging results with the authorization request and be prepared to upload them to RadMD (preferred) or fax imaging reports when requested by NIA to support medical necessity.
- Upload imaging results directly to RadMD during the authorization request.
- If unable to upload, fax imaging using the NIA fax coversheet when requested.
Timing and Frequency Limits
Definitions
Background
This program governs prior authorization for a defined set of outpatient IPM procedures intended for pain control: spinal epidural injections; paravertebral facet joint injections or blocks; paravertebral facet joint denervation (radiofrequency neurolysis); and sacroiliac joint injections. NIA reviews requests for medical necessity against the clinical documentation provided, including prior conservative treatments and imaging when available. The program is limited to outpatient, non-emergent interventions; it is intended to ensure appropriate utilization, member safety, and that services meet accepted standards of medical practice.
Not Covered / Exclusions
The prior authorization program explicitly excludes Emergency Room, inpatient, and intraoperative IPM procedures. Services performed in those settings are outside the scope of the NIA authorization process and do not require prior authorization through NIA.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.