CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pain Management Services (interventional injections and procedures)

Defines coverage, limitations, and prior authorization requirements for pain management interventional services (epidural injections, facet joint injections, radiofrequency denervation, sacroiliac injections) for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPain Management Services (interventional injections and procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain medical review and prior authorization for specific pain management services as listed in Table 1.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoveredEpidural, facet joint, sacroiliac injections and radiofrequency denervation included

Prior authPrior authorization required

EFP ExcludedEFP members excluded

CMP PublishedCMP/CPG status

Coverage Criteria

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPain Management Services (interventional injections and procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain medical review and prior authorization for specific pain management services as listed in Table 1.

SourceLink

On This Page

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Covered Interventional Pain Procedures

Covered when services are medically necessary and meet CMP limits.

Included Services: Interventional pain procedures including epidural injections, spinal facet joint injections, sacroiliac joint injections, and radiofrequency facet denervation are covered when medically necessary.

See Table 1 and applicable Clinical Medical Policies (CMP) for specific frequency limits and prior authorization requirements.

Extended Family Planning (EFP) members are enrolled in a restricted benefit package that does not include pain management services. For details about services covered under the EFP benefit, consult the EFP Benefit Coverage Summary.

The scope of pain management services in this policy excludes the routine or standard use of anesthesia or analgesics provided during surgeries, labor and delivery, and other procedural care. Such perioperative or procedure-related anesthesia/analgesia is not considered part of the interventional pain management benefit described here.

This document does not enumerate additional explicit not medically necessary conditions beyond the listed exclusions. Refer to the applicable Clinical Medical Policies (CMPs) and Table 1 in the policy for specific limits, criteria, and any procedures that require prior authorization or are considered not medically necessary.

Coding and References

References to coding sourcesmixed

No codes listed

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Medical review and prior authorization are required for specific pain management services as listed in Table 1. Lack of prior authorization or medical review may result in claim denial.

See Table 1 for services requiring prior authorization

Documentation Required

Cross-reference Documentation Requirements

Provider must follow documentation cross-references when submitting claims or prior authorization requests. Refer to the Radiology Benefit Coverage Summary for interventional radiology services and fluoroscopic guidance; refer to the Home Health Care Benefit Coverage Summary for IV infusion therapy related to pain management; refer to the DME Benefit Coverage Summary for neurostimulator codes; and refer to the Outpatient Surgery and Procedures Benefit Coverage Summary for neurostimulator services.

Radiology Benefit Coverage Summary — fluoroscopic guidance and interventional radiology
Home Health Care Benefit Coverage Summary — IV infusion therapy
DME Benefit Coverage Summary — neurostimulator codes
Outpatient Surgery and Procedures Benefit Coverage Summary — neurostimulator services

Note

Provider Action / Alert

Render any provider-facing requirement or alert found in the policy preamble: Pain management services described are restricted to introduction/injection of anesthetic agents, facet joint injections, radio frequency facet joint denervation, and other covered medically necessary diagnostic or therapeutic services. Verify member benefit package eligibility (e.g., RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One) prior to authorization or scheduling.

Affected benefit packages: RIte Care; Children with Special Health Care Needs; Substitute Care; Rhody Health Partners; Rhody Health Options Phase One
Services restricted to injections, facet joint procedures, RF denervation, and other medically necessary diagnostic/therapeutic pain management services

Denial Risk

Denial Risk if Authorization Not Obtained

Failure to obtain required prior authorization or complete medical review may lead to claim denial. Follow the Clinical Medical Policies (CMP) for coverage limitations and the comments in Table 1 for specific pain management limits.

See Clinical Medical Policies (CMP) for coverage limitations
Absence of authorization or medical review may trigger denial

Background

Pain management encompasses the assessment of pain and, when appropriate, treatments to address a member’s pain. The interventional procedures covered by this policy include epidural injections, spinal facet joint injections, sacroiliac joint injections, and radiofrequency facet denervation. Care may be delivered across multiple settings and includes procedural interventions, medications, modalities, and devices as indicated by the member’s clinical needs.

Definitions

Pain Management — definition and scope

DefinitionPain Management is the assessment of pain and, if appropriate, treatment in order to assure the needs of members who experience problems with pain are met. Treatment may include medications, other modalities, and medical devices; this policy focuses on introduction/injection procedures (anesthetic injections), facet joint injections, radiofrequency facet joint denervation, sacroiliac joint injections, and other covered diagnostic or therapeutic injections.

ScopeServices covered under this policy are interventional pain procedures performed across multiple settings and limited to injection/introduction procedures and related diagnostic or therapeutic interventions listed above.

Benefit PackagesApplicable benefit packages include RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, and Rhody Health Options Phase One.

CMP/CPG AvailabilityClinical Medical Policy (CMP) published for listed procedures; Clinical Practice Guideline (CPG) status noted in source.

Conservative Treatment Requirements

Frequency Limits and Specific Table References

Specific limits referenced in Table 1 — frequency and limits

Prior authorizationMedical review and prior authorization are required for specific pain management services as listed in Table 1.

Location of specific limitsDetailed frequency limits and service-specific limits are outlined in the comments section of Table 1 of this document and in the referenced Clinical Medical Policies (CMP).

Coverage limitations referencePain management coverage limitations are governed by the appropriate CMPs; see Table 1 comments for procedure-by-procedure limits.

Imaging Requirements

Note

Fluoroscopy required when indicated

Use fluoroscopic guidance for interventional pain procedures when indicated; follow the Radiology Benefit Coverage Summary for the indications and documentation standards.

Not Covered

Pain management services are NOT COVERED for members enrolled in the Extended Family Planning (EFP) benefit; EFP members do not have access to the pain management benefit described in this policy. For a full list of EFP-covered services, see the EFP Benefit Coverage Summary.