Payment was denied because the documentation did not support the medical necessity for the injection procedure. The documentation did not support the trigger points as reasonable and necessary.
There was no indication of symptoms or physical findings that would support the medical necessity of the service at the level billed, in accordance with Medicare Guidelines. For the procedure code 20553 to be considered medically necessary and reasonable, an appropriate payable diagnosis needs to be billed as outlined in the Local Coverage Determination (LCD) (L30155). The claim was billed with the diagnosis codes 724.2, 722.52, 724.4, and 724.02, which were not one of the recognized diagnoses prescribed in the LCD 30155.
The beneficiary was a 65 year old man who complained of lower back pain for one year that was getting progressively worse. He received injections for pain control 10 years before the date of service; he received physical therapy recently that caused him severe pain. He underwent lower back surgery (posterior lumbar interbody fusion [PLIF]) on 03/07/2014. He was taking medications for pain and reported weakness on the left leg; he ambulated with a cane. …show more content…
The neurosurgeon recommended “a course of physical and aquatic therapy for post-op rehabilitation concurrent with a course of three trigger point injections.”
On the dates of service the beneficiary had history and physical examinations; the treatment plan was “Proceed with TPI” (trigger point injections). He received injections for pain control in 3 or more muscles of the lower back. The diagnosis documented was lumbar muscle spasm, which was not a diagnosis covered by the
There was no indication of symptoms or physical findings that would support the medical necessity of the service at the level billed, in accordance with Medicare Guidelines. For the procedure code 20553 to be considered medically necessary and reasonable, an appropriate payable diagnosis needs to be billed as outlined in the Local Coverage Determination (LCD) (L30155). The claim was billed with the diagnosis codes 724.2, 722.52, 724.4, and 724.02, which were not one of the recognized diagnoses prescribed in the LCD 30155.
The beneficiary was a 65 year old man who complained of lower back pain for one year that was getting progressively worse. He received injections for pain control 10 years before the date of service; he received physical therapy recently that caused him severe pain. He underwent lower back surgery (posterior lumbar interbody fusion [PLIF]) on 03/07/2014. He was taking medications for pain and reported weakness on the left leg; he ambulated with a cane. …show more content…
The neurosurgeon recommended “a course of physical and aquatic therapy for post-op rehabilitation concurrent with a course of three trigger point injections.”
On the dates of service the beneficiary had history and physical examinations; the treatment plan was “Proceed with TPI” (trigger point injections). He received injections for pain control in 3 or more muscles of the lower back. The diagnosis documented was lumbar muscle spasm, which was not a diagnosis covered by the