CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pain Management Services (interventional injections and denervation)

Defines coverage, limitations, and authorization requirements for interventional pain management services including epidural injections, facet joint injections, sacroiliac joint injections, and radiofrequency facet joint denervation for Neighborhood Health Plan of Rhode Island members in specified benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPain Management Services (interventional injections and denervation)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 4, 2010

Next Review DateN/A

Key ActionSubmit prior authorization requests with documented medical necessity for specific interventional pain procedures per the policy and Table 1.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4primary procedure categories listed

5benefit packages referenced

2010document creation year (2010)

Covered Services, Limitations, and Exclusions

Covered Services / Included Procedures

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ALL of the following

Epidural injections (cervical, thoracic, lumbar) are included as a covered benefit when medically necessary and authorized.
Spinal facet joint injections are included as a covered benefit when medically necessary and authorized.
Sacroiliac joint injections are included as a covered benefit when medically necessary and authorized.
Radiofrequency facet joint denervation (radiofrequency ablation) is included as a covered benefit when medically necessary and authorized.

Coverage Limitations and Authorization

Coverage is subject to medical review and prior authorization for specific management services as indicated in Table 1 (comments).

ALL of the following

Medical review and authorization (prior authorization) are required for specific pain management services; see Table 1 for service-specific limits and comments.
Pain management services are restricted to the introduction/injection of anesthetic agents, facet joint injections, radiofrequency facet joint denervation, and other covered medically necessary diagnostic or therapeutic services.
Episodes of care can occur across multiple settings; coverage applies within those settings as detailed in benefit service category criteria.

Exclusions

Services and situations that are not covered under this policy:

ANY of the following

Extended Family Planning (EFP) members: management services for pain are not included in the EFP restricted benefit package.
Standard use of anesthesia or analgesics during surgeries, labor and delivery, and other procedures is not included as pain management services under this policy.

Authorization and Documentation Requirements

Prior Authorization

Prior authorization required for specific pain management services

Medical review and prior authorization are required for specific interventional pain management procedures; providers must submit prior authorization requests per Table 1 and demonstrate documented medical necessity as part of the authorization process.

Documentation Required

Documentation of medical necessity

Providers must document the clinical indications that support the use of interventional pain procedures (for example, diagnosis and prior conservative therapy) as part of the authorization request and for medical review.

Clinical and Administrative Context

This policy governs interventional pain management services with a focus on injections and radiofrequency denervation. Its intent is to ensure such procedures are provided when medically necessary and appropriately authorized, and to delineate exclusions such as routine perioperative anesthesia.

See DME and Outpatient Surgery and Procedures Benefit Coverage Summaries for neurostimulator coding and services.

Defined Terms

Pain Management

Pain ManagementAssessment of and, if appropriate, treatment to meet the needs of members who experience pain; may include medications, modalities, and medical devices, and provided across multiple settings.

Scope of ServicesIncludes introduction/injection of anesthetic agents, facet joint injections, radiofrequency facet joint denervation, and other covered medically necessary diagnostic or therapeutic services.

SettingsServices can be provided across multiple settings; coverage applies within those settings as detailed in the benefit service category criteria.

Policy Dates and Version History

Effective date: 2010-06-04. Last review: 2013-01-08. Next review: not specified.

2010-06-04Created

Policy created establishing coverage criteria for interventional pain management services including epidural injections, spinal facet joint injections, sacroiliac joint injections, and radiofrequency facet joint denervation.

2011-01-10CMC Review

Clinical Medical Committee (CMC) conducted a review of the policy.

2013-01-08CMC ReviewLatest

Clinical Medical Committee (CMC) conducted a subsequent review of the policy; this is the most recent documented review.

Scope Summary