Some pain management providers feel they must resort to putting patients back on opioids because their Medicare claims for facet-joint interventions are being denied, even though they satisfy the requirements of their local coverage determination (LCD), according to an attorney. Auditors allegedly are holding providers to requirements for the procedures—which treat chronic neck and back pain—that aren’t in the LCD and are applying the coverage criteria inconsistently. If that’s the case, it doesn’t bode well for providers, because facet-joint interventions are coming under scrutiny across the country.

“The providers are so frustrated,” said Richelle Marting, an attorney and certified coder in Olathe, Kansas. “Pain doctors are wanting to get patients off opioids, and we have patients who could barely walk getting these injections and now can play golf, and Medicare doesn’t want to pay for it.”

Providers may want to pay attention to the possibility of audits coming their way because facet-joint interventions are being audited by Medicare’s supplemental medical review contractor (SMRC)^[1] and Medicare administrative contractors (MACs) in targeted probe and educate (TPE). Another shoe will drop soon because CMS proposed to add facet-joint interventions to the hospital outpatient prior authorization process in 2023, and they already have been the subject of several HHS Office of Inspector General (OIG) audits.^[2]

Marting has had a front-row seat for MAC and SMRC audits, and they worry her. “This is the first topic I have seen in a while with such substantively different interpretations with substantively similar documentation,” she remarked. The auditors for the MAC (WPS Government Health Administrators) and the SMRC have been “denying coverage based on wildly inconsistent policy interpretations and inferring language and imposing requirements that don’t exist in the plain language of the coverage policy.”