CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pain Coverage Summary 10.03.13 Through 09.30.21

Defines coverage, limitations, exclusions, and prior authorization requirements for pain management services including epidural injections, facet joint injections, radiofrequency facet denervation, and sacroiliac joint injections for specified Rhode Island Medicaid benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPain Coverage Summary 10.03.13 Through 09.30.21

Policy CodePolicy N/A

Change TypeRevision / PEC review

Effective DateJun 4, 2010

Next Review Date

Key ActionObtain medical review and prior authorization and document medical necessity for specific pain management services as outlined in Table 1 and referenced Clinical Medical Policies.

SourceLink

POLICY UPDATE CHANGES

PEC revision dated 10/3/13 recorded in version history.

4Core procedure categories listed (epidural, facet, sacroiliac, radiofrequency)

5Included benefit packages

1Excluded member group (EFP)

Coverage Summary

This policy covers pain management services limited to injections and interventional spinal procedures. Core procedure categories included are epidural injections, facet joint injections, sacroiliac joint injections, and radiofrequency (RF) facet joint denervation. Coverage language here is restricted to these interventional procedures and injections; other pain-related services (e.g., routine anesthesia for surgery, labor and delivery) are excluded. Applicable benefit packages include RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, and Rhody Health Options Phase One.

Medical Necessity / Coverage Criteria

Covered Services / General Criteria

Pain management services covered when provided as medically necessary diagnostic or therapeutic procedures and not otherwise excluded; medical review and prior authorization required for specific services per Table 1:

Service types: Service is one of: introduction/injection of anesthetic agents, facet joint injections, radiofrequency facet joint denervation, sacroiliac joint injections, epidural injections, or other medically necessary diagnostic or therapeutic pain management procedures.
Medical necessity and prior authorization: Service is medically necessary as determined by medical review / prior authorization where applicable (see Table 1).
Included benefit packages: Service is provided to a member enrolled in an included benefit package (RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One).
Not standard anesthesia/analgesia: Service is not part of standard anesthesia/analgesia for surgery, labor and delivery, or other non-pain-management procedures.

Billing and cross-references: For fluoroscopic guidance, IV infusion, DME neurostimulator codes, and outpatient surgery/neurostimulator services, providers must follow the respective Radiology, Home Health Care, DME, and Outpatient Surgery Benefit Coverage Summaries.

Provider Actions & Billing Impact

Prior Authorization

Prior Authorization Required for Specific Pain Management Services

Medical review and prior authorization are required for specific pain management services as outlined in Table 1 and the referenced Clinical Medical Policies (Epidural Injections; Radio Frequency Facet Joint Denervation; Sacroiliac Joint Injections).

See Table 1 and referenced CMPs

Documentation Required

Medically Necessary Determination

Providers must document medical necessity for diagnostic or therapeutic pain management procedures to support medical review/prior authorization.

Billing Rule

Billing Guidance Cross-References

For fluoroscopic guidance, IV infusion, DME neurostimulator codes, and outpatient surgery/neurostimulator services, providers must follow the respective Radiology, Home Health Care, DME, and Outpatient Surgery Benefit Coverage Summaries.

Codes & Referenced Policies

Referenced Clinical Medical Policies (CMP) / Procedure Topicsmixed

CMP topics referenced: Epidural Injections; Radio Frequency Facet Joint Denervation; Sacroiliac Joint Injections

Benefit Packages Includedmixed

RIte Care	Included benefit package
Children with Special Health Care Needs	Included benefit package
Substitute Care	Included benefit package
Rhody Health Partners	Included benefit package
Rhody Health Options Phase One	Included benefit package

For code-level prior authorization requirements and detailed procedure-level criteria, see Table 1 in this document and the referenced Clinical Medical Policies: Epidural Injections, Radio Frequency Facet Joint Denervation, and Sacroiliac Joint Injections. Medical review and prior authorization are required for specific pain management services as indicated in Table 1.

Background & Definitions

Background: Pain management services include assessment and treatment modalities which may involve medications and interventional procedures. This coverage summary is limited to the introduction/injection of anesthetic agents and interventional pain procedures (facet joint injections, radiofrequency facet denervation, sacroiliac joint injections, epidural injections) and cross-references the detailed Clinical Medical Policies for limits and clinical criteria.

Pain Management: The assessment of pain and, if appropriate, treatment in order to assure the needs of members who experience problems with pain are met; treatment of pain may include the use of medications or application of other modalities and medical devices.