The patient responded well to every injection. The chart never said where the series was going.
Key Takeaways
- Some payers expect facet injections to lead somewhere: usually radiofrequency ablation, or a documented reason it is not an option.
- Frequency limits matter. A fourth session in ten months is right at the edge of common limits.
The case
A 58-year-old patient with chronic lumbar facet joint pain had received three lumbar facet injections over the previous ten months. His physician requested a fourth. The request was going to Fidelis Care.
The chart showed he had responded well to each injection. It did not document any plan to move to radiofrequency ablation (RFA).
Why this request was at risk
Many payers, including Medicare, treat diagnostic facet blocks as a step toward RFA, which is intended to give longer-lasting relief. Under those policies, therapeutic facet injections are covered only when the patient is not a candidate for RFA, and the reason must be documented. In some cases, they also limit therapeutic sessions per spinal region in a rolling 12-month period.
Sources: CMS Medicare Coverage Database: Facet Joint Interventions for Pain Management; Blue Cross Blue Shield of Michigan summary of the Medicare facet joint LCD
This chart showed a good response but no endpoint. To a reviewer, that looks like an open-ended series of injections, which is a common reason for a medical necessity denial. The fourth session in ten months also put the request close to frequency limits.
What our team checked
- The injection history, with dates and the patient’s documented response to each
- Whether the chart documented a plan to proceed to RFA after a positive response, or a reason the patient is not a candidate
- The request against the plan’s frequency limits
- The exam note’s description of the pain pattern
What we did
Our specialist flagged the missing plan and paused the request. We asked the practice for the physician’s documentation of the next step, so the submission would show the reviewer where the injection series was heading.
The documents that close the gap
Where our team sees this most often
Fidelis Care, Aetna Medicare, and Aetna commercial plans.
A question for your team
When your physicians order the next injection, does the note say what comes after it?
Want a prior authorization team that reads the chart and the plan before every submission? Talk with DataMatrix Medical.
More from this series: see all six prior authorization case studies.
This case is drawn from a real prior authorization request our team handled. We removed identifying details to protect patient privacy. Payer policies change and vary by plan, so the same steps will not produce the same result in every case. This article is educational and is not legal, billing, or clinical advice.
Nathaniel Smathers is the VP of Client Education and Marketing. He is also a long time contributor of the DataMatrix Medical blog and has a background in healthcare content creation for over a decade. Nathaniel is passionate about exploring the intersections of healthcare, data analysis, and digital innovation.
