SCS Headaches

[PainBrain78]

I would love to do PNS for occipital neuralgia however insurances currently do not cover for the most part. I know there’s a clinic doing them and have four leads placed (2 greater occipital nerve and 2 supraorbital). I’m not sure how they get reimbursed for this.

I’m considering placing leads in posterior occipital region and billing SCS for C2 radiculopathy.

Thoughts?

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[bedrock]

I would love to do PNS for occipital neuralgia however insurances currently do not cover for the most part. I know there’s a clinic doing them and have four leads placed (2 greater occipital nerve and 2 supraorbital). I’m not sure how they get reimbursed for this.

I’m considering placing leads in posterior occipital region and billing SCS for C2 radiculopathy.

Thoughts?

supraorbital leads are unnecessary for chronic occipital headache. There are headache syndromes that include the frontal/orbital area, for which you could consider supraorbital leads. However, cosmetics are a major issue, so very very few patients are candidates for supraorbital leads.

That said, there are definitely a number of patients with recalcitrant occipital headaches that benefit from GON leads. These are much easier to live with for the patient as well. I've done 7 cases with good success in 5 out of 7. However, that was in a previous practice 8 years ago. I can't speak to how to today get PNS authed for occipital headaches, unless you go down the road of calling it a C2 nerve root type 2 CRPS....

 

[PainBrain78]

supraorbital leads are unnecessary for chronic occipital headache. There are headache syndromes that include the frontal/orbital area, for which you could consider supraorbital leads. However, cosmetics are a major issue, so very very few patients are candidates for supraorbital leads.

That said, there are definitely a number of patients with recalcitrant occipital headaches that benefit from GON leads. These are much easier to live with for the patient as well. I've done 7 cases with good success in 5 out of 7. However, that was in a previous practice 8 years ago. I can't speak to how to today get PNS authed for occipital headaches, unless you go down the road of calling it a C2 nerve root type 2 CRPS....

That’s kind of what I’m getting at. Would I go to prison? Lol

 

[lobelsteve]

I would love to do PNS for occipital neuralgia however insurances currently do not cover for the most part. I know there’s a clinic doing them and have four leads placed (2 greater occipital nerve and 2 supraorbital). I’m not sure how they get reimbursed for this.

I’m considering placing leads in posterior occipital region and billing SCS for C2 radiculopathy.

Thoughts?

That’s fraud. Criminal act.

 

[BobBarker]

I would assume you could get an older Boston system for a much lower price and do it as PNS for chronic mononeuropathy without any funny business needed. I think they are the only ones left with stock of a decent, tonic, rechargeable SCS. A restore ultra or restore sensor would be possible also if there are any around.

 

[SC Tian]

I did occipital stims for Medicare, or medicare replacement insurance, can't recall difficulties getting covered. for commercial insurance, I use cervical neuritis, and do dorsal column stim

Use of spinal cord stimulation in treatment of intractable headache diseases - PubMed

Headache diseases remain one of the leading causes of disability in the world. With the development of neuromodulation strategies, high cervical spinal cord stimulation (hcSCS) targeting the trigeminocervical complex has been deployed to treat refractory headache diseases. In this article, we...

pubmed.ncbi.nlm.nih.gov

 

[Ducttape]

you probably wont encounter difficulties from medicare. but they may audit your charts in some remote future and require repayment if the requirements spelled out in the LCDs are not met.

thats the problem with "not recalling" difficulties with Medicare.

follow the LCD and document, document, document.

 

[SC Tian]

you probably wont encounter difficulties from medicare. but they may audit your charts in some remote future and require repayment if the requirements spelled out in the LCDs are not met.

thats the problem with "not recalling" difficulties with Medicare.

follow the LCD and document, document, document.

thanks for reminding us, we looked into the LCD very carefully.

 

[Orin]

PNS at C2 lamina for suboccipital ONS has going well with SPR for my patients, less than 5 though. Haven't had any come back in the last 9 months but am ready to do a Curonix or Nalu implant to mimic it.

Removed 2 of those rings of supraorbital/occipital systems from some place in Texas this past year. At least they come out easily

 

[CleanUp]

you probably wont encounter difficulties from medicare. but they may audit your charts in some remote future and require repayment if the requirements spelled out in the LCDs are not met.

thats the problem with "not recalling" difficulties with Medicare.

follow the LCD and document, document, document.

As an aside what happens when Medicare starts auditing charts and what was done is not consistent with LCDs? Do they demand back charges? Can a physician just surrender their license and move to another state and retire?

The reason I ask is because I not infrequently encounter Medicare patients who have had 5-7 epidurals in less than 12 months from another physician and then become upset when I tell them another epidural isn’t indicated nor covered.

 

[BobBarker]

The other doc isn’t getting paid for all of that unless he is changing body regions and rotating interlaminar vs tfesi. Medicare catches onto that stuff earlier than most think. I know from getting pinched on several b/l lumbar rfa 10m out from the patient having the same procedure but r/l in different sessions elsewhere. They caught it immediately and never paid.

 

[bedrock]

The other doc isn’t getting paid for all of that unless he is changing body regions and rotating interlaminar vs tfesi. Medicare catches onto that stuff earlier than most think. I know from getting pinched on several b/l lumbar rfa 10m out from the patient having the same procedure but r/l in different sessions elsewhere. They caught it immediately and never paid.

Damn. I didn’t realize we had to pay for the sins of others.

 

[nvrsumr]

How could you possibly know when no prior Auths

 

[Ronin1]

We have a local guy that does three shots epidural or facets then has them sign abn and keeps on injecting. See up to 14 in a year from them

 

[painfree23]

We have a local guy that does three shots epidural or facets then has them sign abn and keeps on injecting. See up to 14 in a year from them

Is there any data that shows this many spinal injections is a bad thing? Or are we just upset about the Medicare fraud. I would never do anything like this but just playing devils advocate

 

[lobelsteve]

Is there any data that shows this many spinal injections is a bad thing? Or are we just upset about the Medicare fraud. I would never do anything like this but just playing devils advocate

Is it a good thing? We know it is a bad thing. OP, CAD, DM, infection risk-immunosuppression.
And that is just the medical risk. Risk of injury.
But why? Greed.

 

[PainBrain78]

As an aside what happens when Medicare starts auditing charts and what was done is not consistent with LCDs? Do they demand back charges? Can a physician just surrender their license and move to another state and retire?

The reason I ask is because I not infrequently encounter Medicare patients who have had 5-7 epidurals in less than 12 months from another physician and then become upset when I tell them another epidural isn’t indicated nor covered.

What are LCDs? I’m so glad this forum is anonymous. 😂

 

[buddababa]

What are LCDs? I’m so glad this forum is anonymous. 😂

bruh really??

 

[Orin]

bruh really??

Come on. Very few fellowship faculty understand/cover local coverage determinations or insurance guidelines

 

[CleanUp]

What are LCDs? I’m so glad this forum is anonymous. 😂

Local coverage determinations

The way I understand it it is like divisions of the United States like East, West, Midwest, South.

Each areas has different reimbursements and what is covered

Someone please feel free to correct me or add anything.

 

[Ducttape]

As an aside what happens when Medicare starts auditing charts and what was done is not consistent with LCDs? Do they demand back charges? Can a physician just surrender their license and move to another state and retire?

The reason I ask is because I not infrequently encounter Medicare patients who have had 5-7 epidurals in less than 12 months from another physician and then become upset when I tell them another epidural isn’t indicated nor covered.

its all about money.

they may declare that someone is doing medicare fraud but most commonly they just say that the injection did not meet guidelines and are forced to pay back the government.

Is there any data that shows this many spinal injections is a bad thing? Or are we just upset about the Medicare fraud. I would never do anything like this but just playing devils advocate

there are case reports of adhesive arachnoiditis from epidurals.

cushings syndrome has been reported from excessive steroid injection.

there is data suggesting steroid injections can lead to avascular necrosis and tendency towards osteoporosis.

there is a lot of data showing long term effects of glucocorticoids given systemically not only with bone but wit endocrine dysfunction. there are studies suggesting hypertension, diabetes, MI, stroke, cataract formation,


for example:

Epidural Steroid Injections Acutely Suppress Bone Formation Markers in Postmenopausal Women - PubMed

These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation...

pubmed.ncbi.nlm.nih.gov