PDF Version
TO: ALL
Providers
RE: Implementation
of Prior Authorization for Spinal Facet-Joint Interventions
Prior
Authorization: Effective for dates of service on or after May 1, 2024, the Alabama
Medicaid Agency (Medicaid) updated the prior authorization (PA) program to
include facet-joint intervention procedures. Specifically, procedure codes
64490-64495 and 64633-64636, require PA prior to services rendered when
performed in the office, outpatient hospital, ambulatory surgical center, or
pain management clinic settings.
All the following requirements must
be met for medical necessity to be determined:
|
Diagnostic injection:
|
Denervation:
|
Therapeutic injection:
|
|
1.
≥ 3 months of documented back or neck pain
that interferes with the recipients ‘activities of daily living (ADLs).
2.
≥ 6 weeks of conservative therapy (e.g.,
physical therapy, home exercise program, activity modification) with documented
failure of pain to respond to treatments.
3.
≥ 3 weeks NSAID therapy or NSAID is contraindicated
or was not tolerated.
4.
Clinical findings suggestive of facet joint
syndrome as evidenced by the absence of nerve root compression.
5.
Imaging studies suggestive of no other cause
for the pain (e.g., disc herniation, radiculitis, discogenic or sacroiliac
pain).
6.
No prior spinal fusion surgery in the vertebral
level being treated.
7.
A facet joint denervation intervention is
being considered.
|
1.
The recipient has had up to two
medically reasonable and necessary diagnostic facet joint injections with each
one providing a consistent minimum of 80% pain relief.
2.
≥ 3 months of documented back or neck
pain that interferes with the recipients’ ADLs.
3.
≥ 6 weeks of conservative therapy (e.g.,
physical therapy, home exercise program, activity modification) with documented
failure of pain to respond to treatments.
4.
≥ 3 weeks NSAID therapy or NSAID is contraindicated
or was not tolerated.
5.
Clinical findings suggestive of facet
joint syndrome and imaging studies suggestive of no other cause for the pain
(e.g., fracture, tumor, infection, disc herniation, radiculitis, discogenic
or sacroiliac pain, etc.).
6.
No prior spinal fusion surgery in the
vertebral level being treated.
|
1.
Recipient
must meet all the criteria for denervation.
2.
Documentation
of why the recipient is not a candidate for denervation.
3.
The recipient has had 2 medically reasonable and necessary
diagnostic facet joint injections with each providing a consistent minimum of
80% pain relief.
4.
Subsequent therapeutic
injections at the same anatomic site results in at least 50% pain relief for
at least three months from the prior therapeutic injection or at least 50% improvement in
the ability to perform ADLs as compared to baseline measurements.
|
For general information regarding
prior authorization, refer to the Provider Billing Manual - Chapter 4,
Obtaining Prior Authorization.
Documentation Requirements: Providers should
include the following documentation with their facet-joint interventions PA
request:
- Clear indication
of what is being requested
- History and physical
- Physician orders
and progress notes
- Diagnostic test
results
- Pain history to
include location, severity and duration
- Evidence of failed
conservative management
- Patient response
to prior facet-joint interventions, if applicable
- Completed Alabama
Prior Review and Authorization Request Form 342
Frequency
Limitations:
Effective for dates of service on or after May 1, 2024, Medicaid established the
following frequency limitations for spinal facet-joint intervention procedures when
performed in the office, outpatient hospital, ambulatory surgical center, or
pain management clinic settings.
The following Diagnostic
Facet-Joint Injection procedure codes will be limited to one spinal region (e.g., cervical/thoracic, or
lumbar/sacral) per session, with a maximum of two joints per session. In total,
each covered spinal region is allowed four sessions per calendar year:
|
Procedure Code
|
Procedure Code Short Descriptor
|
PA Required
|
|
64490
|
INJ PARAVERT F JNT C/T 1 LEV
|
Yes
|
|
64491*
|
INJ PARAVERT F JNT C/T 2 LEV
|
Yes
|
|
64493
|
INJ PARAVERT F JNT L/S 1 LEV
|
Yes
|
|
64494*
|
INJ PARAVERT F
JNT L/S 2 LEV
|
Yes
|
Note:
Codes with * are not applicable to outpatient hospital and ambulatory surgical
centers.
The following
Facet-Joint Denervation procedure codes will be limited to one spinal region (e.g., cervical/thoracic, or
lumbar/sacral) per session, with a maximum of four joints per session. In
total, each covered spinal region is allowed two sessions per calendar year:
|
Procedure Code
|
Procedure
Code Short Descriptor
|
PA
Required
|
|
64633
|
DESTROY
CERV/THOR FACET JNT
|
Yes
|
|
64634
|
DESTROY C/TH
FACET JNT ADDL
|
Yes
|
|
64635
|
DESTROY LUMB/SAC
FACET JNT
|
Yes
|
|
64636
|
DESTROY L/S
FACET JNT ADDL
|
Yes
|
The
following Therapeutic Facet-Joint Injection procedure codes are non-covered and
describe a third and additional level. Therapeutic Facet-Joint injections are medically necessary only if a recipient is
not a candidate for denervation and utilize the same restrictions as diagnostic
injections:
|
Procedure Code
|
Procedure
Code Short Descriptor
|
PA
Required
|
|
64492*
|
INJ PARAVERT F
JNT C/T 3 LEV
|
Yes
|
|
64495*
|
INJ PARAVERT F
JNT L/S 3 LEV
|
Yes
|
Note:
Codes with * are not applicable to outpatient hospital and ambulatory surgical
centers.
See LCD L34892 –
Facet Joint Interventions for Pain Management for more information.
A 45-day grace period is permitted
for providers to retroactively submit PA requests. After July 1, 2024, all PA
requests must be obtained prior to services rendered.
For billing questions, call the Gainwell
Technologies Provider Assistance Center at 1-800-688-7989. Send policy questions
to Medicaid’s Physician Program at Physicians.Program@medicaid.alabama.gov.
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2024
American Medical Association and © 2024 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.