Inappropriate billing of anesthesia services for epidural steroid injections (ESI) and facet joint injections for pain management

First Coast has detected an upward trend in the inappropriate billing of anesthesia services with ESI and facet joint injections. General anesthesia is considered not medically reasonable and necessary when performing epidural steroid injections and facet joint injections for pain management. This article is intended to remind providers of the instruction in the local coverage determinations (LCDs) regarding limitations of coverage. 

In LCD L33906 Epidural Steroid Injections for Pain Management, the limitations section specifically instructs:

“Use of Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore, is not considered medically reasonable and necessary. Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient”.

In LCD L33930 Facet Joint Interventions for Pain Management, the limitations section specifically instructs:

“General anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.”

It would be considered exceptional and unique for a patient to require anesthesia for these services, and the documentation in the medical record must support the need for such sedation for the specific patient, the specific service, and the specific encounter. 

Providers may submit an appeal if they feel there is an exceptional or unique case where anesthesia is justified and the patient’s medical record clearly supports the medical necessity.