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Legislation in Congress can help address these problems in Medicare Advantage

Recently, a 75-year-old man came to my clinic with lower extremity pain and a developing foot drop due to a spinal nerve root compression. He had undergone lumbar fusion surgery years earlier. His MRI and CT scans showed severe foraminal compression below his previous spinal fusion site. We immediately scheduled him for urgent surgery to prevent the worsening of his weakness. His surgery was initially denied because the radiology reports from his imaging studies did not describe the foraminal compression. My interpretation of the imaging as his treating surgeon did not satisfy the health plan. Even after a peer-to-peer discussion, the Medicare Advantage plan refused to authorize his surgery.

To satisfy his health plan and before surgery could proceed, additional radiologists were required to re-read the films and specifically describe the foraminal compression before his insurer would allow the surgery. This entire process, including a formal appeal of the initial decision, took weeks. While we were jumping through these administrative hoops, his weakness was getting worse. Fortunately, following surgery, the patient did well, but not all patients will be so lucky.

Another patient of mine, a 68-year-old avid surfer, needed an extensive reconstruction of a lumbar spinal deformity he developed after an accident years earlier. He lived in a rural region of California and came to Stanford for his surgery. Due to the complexity of his case, he needed to be treated at an academic medical center. His insurer denied covering his surgery if it was done at Stanford, stating that the patient should be treated at a facility in his part of the state. Unfortunately, no such facility could provide the care he needed.
 
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Percutaneous adhesiolysis has faced multiple issues related to coverage in the past few years. Initially, Noridian issued a noncoverage decision, followed by Palmetto issuing an experimental procedure decision.
 
Since then, we have incorporated into discussions on epidural LCD. While it was discussed in epidural LCD, it was not issued in the final consideration. We continued our efforts for coverage of this procedure and general consensus was that they all will be covering as any other Medicare services in the absence of a particular policy. We continue to face questions with Palmetto and Noridian.
 
After many years of advocacy, we have finally succeeded in getting coverage for this important procedure in all states, including all Palmetto and Noridian states in the United States.

We are very grateful to the Multijurisdictional Committee that convened considering epidural injections on 2/11/2021 for considering percutaneous adhesiolysis. We are also grateful to the Medical Directors of Palmetto and Noridian MACs for their prompt response. 

Enclosed, please see the letters written to Palmetto and Noridian and the responses from Palmetto and Noridian.
 
It is crucial to perform these procedures based on appropriate indications and medical necessity. ASIPP epidural guidelines show the evidence basis, as well as indications and medical necessity, in addition to numerous other systematic reviews and randomized controlled trials.
 
Enclosed, please find a review of indications and medical necessity from epidural guidelines. You may also visit the entire guideline for further information. 








Many Americans across the political spectrum are clamoring for federal action on guns in the wake of a mass shooting at an Uvalde, Texas, elementary schoola Buffalo, N.Y., grocery store and hundreds of other places.

But buried in a bipartisan compromise hashed out by the U.S. Senate on Tuesday is an unrelated provision they might not be so happy about. Apropos of nothing, the gun bill would enhance the exemption drug middlemen working with Medicare have from the federal Anti-Kickback Statute.” 

That means, in this era of soaring costs, Senate negotiators decided to further insulate the nation’s largest health care companies from a federal law against accepting “any kickback, bribe, or rebate” — using a bill that’s supposedly about regulating guns. 

NEXT EXAM DATES:

Part I
July 30, August 27, September 17, October 22, November 19 & December 17

Part II
September 23





Recent study highlights benefits and builds on previous research

Most of the long-term pharmacotherapeutic options for treating chronic pain have failed us over the years in one way or another. The tragic results of opioid overprescribing need no further review. Adverse effects from nonsteroidal anti-inflammatory (NSAID) overuse are more insidious but may in fact confer (or at least contribute to) even greater morbidity and mortality given their far greater prevalence. (While gastric and renal toxicity get the most airplay, vascular injury including coronary and cerebrovascular issues may comprise the most serious harms from these ubiquitous medications.) Many of the potential long-term individual and community implications of marijuana use for pain remain unknown, but some evidence suggests potential harms involved with chronic use.

When confronted with serious chronic pain, then, what's a caring physician to do?

This month, the highlight (non-funded) study carried out over the past few years on low-dose naltrexone (LDN), which builds on previous research in this area. For those in a hurry, I'll start with the highlights and circle back to basic science a little later, but for starters, I want to point out that our most intriguing and encouraging finding is that so-called neuropathic pain may benefit even more from LDN than the so-called nociceptive or inflammatory pain states that it has been directed at over the past 20 years.




In 9-0 decision, Supreme Court justices vacate lower court decision

The Supreme Court on Monday ruled unanimously in support of two doctors convicted of prescribing opioids without a "legitimate" medical purpose, arguing that there should be a higher standard of proof in prosecuting such cases.

A provision of the Controlled Substances Act (CSA) declares it a federal crime for a person to knowingly or intentionally distribute or dispense controlled substances, such as opioids, "except as authorized."

At the core of the consolidates cases in Ruan v. United States -- brought by Xiulu Ruan, MDof Alabama, and Shakeel Kahn, MD, of Wyoming and Arizona -- is the question: At what point does prescribing powerful and addictive painkillers to a patient become a criminal act? Or more specifically, is criminal intent necessary to convict physicians for distributing substances outside of medical norms.







"Tracking more than about five licenses becomes very cumbersome, time-consuming, and expensive," says Andrew Wilner, MD, internist, neurologist, and epilepsy specialist. "At one point, I had 10 licenses, and I've cut it back to about four to be more manageable. I wasn't using them and it didn't look like I ever would."

Wilner, who has worked in locum tenens for decades, says he kept these state licenses because he has a permanent job in Tennessee; he worked before in Arizona and might work locum tenens and/or retire there; he might retire in Florida; and he has worked in South Dakota before and might work locum tenens there.

Theresa Rohr-Kirchgraber, MD, professor of clinical medicine at AU/UGA Medical Partnership in Georgia, holds licenses in that state, Indiana, and North Carolina.

Please plan to join us at the
2023 ASIPP Annual Meeting
March 16-18 National Harbor, Maryland

Register Early
More details will be posted on our website at asipp.org.
Registration begins October 2022.
For meeting or exhibitor/sponsor information:
Email Karen Avery at kavery@asipp.org or call 270.554.9412 ext 4210
- ASIPP Members Only Site Information -
  1. To log in for the first time you will need to click “forgot password” at the bottom of the login window.
  2. Check your email and then log in as directed.
  3. If you have problems logging into your account, click here.
Pain Medicine Case Reports (PMCR) and Editor-in-Chief Alaa Abd-Elsayed, MD, PhD would like to invite you to submit case reports and case series to the PMCR journal. Your article will be published free of charge.

Open access journals are freely available online for immediate worldwide open access to the full text of published articles. There is no subscription fee for open access journals. Open access journals are no different from traditional subscription-based journals: they undergo the same peer-review and quality control as any other scholarly journal.

Interested in becoming a member of the PMCR Editorial Board?
Editorial board members are asked to review 2-6 manuscripts per year. Please submit your most up-to-date CV to sgold@asipp.org for consideration.

For more information or to submit your articles, click here.
| CASE REPORT |


Ilene Ruhoy, MD, PhD, and Lorrin M. Koran, MD


Abstract
BACKGROUND: Most patients with gadolinium deposition disease (GDD) report early onset of persistent neuropathic pain. No widely available or rapidly acting pain relief method has been reported.

CASE PRESENTATIONS: Five GDD patients without benefit from non-opioid pain relievers and with no history of opioid treatment received a clinical practice trial of open-label, low-dose naltrexone (LDN). Four had received intravenous Ca-DTPA chelation. Before starting LDN, patients rated their pain on a scale of 0 to 10. Patients rated the degree of pain relief weekly using the Global Clinical Impression – Improvement Scale. Pain was very much or much improved for 4 patients, starting during week 2 in one patient and week 4 in 3 patients. Pain relief began at naltrexone dose 3.0 to 4.5 mg per day and reached a maximum after 4 to 8 weeks.

CONCLUSION: These case results suggest that a well-designed, adequately powered, controlled trial of LDN in GDD patients is merited.

KEY WORDS: Case series, gadolinium, naltrexone, pain

| RANDOMIZED CONTROLLED TRIAL |


Mohamed E. Abdel-Ghaffar, MD, Salah A. Ismail, MD, Reda A. Ismail, MD, Mostafa M. Abdelrahman, MD, and Mohamed E. Abuelnaga, MD


Abstract
BACKGROUND: Pain due to inoperable upper abdominal malignancies is a challenging condition that needs a multimodal analgesic regimen to be managed properly. Celiac plexus alcohol neurolysis was proved to be effective in relieving such type of pain; however, there is no consistent data about the optimal volume to be used to maintain the balance between the neurolytic effect and the destructive effect of alcohol.
OBJECTIVES: We aim to compare the analgesic effect of 2 different volumes of alcohol to improve the outcome of interventional management.
STUDY DESIGN: This was a randomized controlled double-blinded interventional clinical trial.
SETTING: Single university hospital.
METHODS: Thirty-two patients who suffered from abdominal pain due to unresectable abdominal malignancies were randomly allocated to receive in a single injection ultrasound-guided celiac plexus neurolysis (CPN) with injection of either 20 mL 70% alcohol (CPN20 group) or 40 mL 70% alcohol (CPN40 group). The primary outcome was the post-procedure pain score, while the secondary outcomes included the post-procedure total daily opioid consumption and quality of life (QOL).
RESULTS: There was no statistically significant difference between both groups regarding visual analog scale (VAS) scores at all time points (P-value > 0.05); however, comparisons in each group revealed significantly reduced VAS scores at all time points following the intervention when compared to the baseline. Daily morphine equivalent consumption doses showed statistically significant differences between the baseline and each time point in both groups (P-value < 0.05), with no significant difference between both groups at each time point (P-value > 0.05). There was no statistically significant difference between the study groups regarding all domains in quality of life assessment at all time P > 0.05). The scores of most time points in all domains were different significantly when compared to the baseline readings in both groups, with a tendency to decline over time in both groups approaching the baseline values.
LIMITATIONS: This was a single-center study with a relatively small sample size. Further prospective, multicenter, randomized, and controlled studies with a larger sample size are required to confirm the effects in this study. 
CONCLUSIONS: During ultrasound-guided CPN for patients with inoperable upper abdominal cancers who failed medical management, a volume of 20 mL is as effective as 40 mL of 70% alcohol regarding pain control, opioid consumption, quality of life, and procedure-related complications.
KEY WORDS: Upper abdominal pain, upper abdominal malignancy, ultrasound-guided celiac plexus block, RCT, celiac plexus neurolysis, alcohol neurolysis, opioid consumption, quality of life

| RANDOMIZED TRIAL |


Ji Hee Hong, MD, PhD, Ki Beom Park, MD, PhD, and Sung Won Jung, MD, PhD


Abstract
BACKGROUND: Inadvertent intravascular injection of local anesthetics can lead to false negative results following a lumbar medial branch block (MBB) performed to diagnose facet joint origin pain. A previous study demonstrated that the type of needle could affect the incidence of intravascular injection rates.
OBJECTIVES: The primary endpoint of this study was to compare the incidence of intravascular injection during lumbar MBB between the Quincke and Touhy needles. The secondary endpoint of this study was to compare the injection time, radiation dose, and patient discomfort during lumbar MBB between the needle types.
STUDY DESIGN: Prospective randomized trial.
SETTING: An interventional pain management practice in South Korea.
METHODS: The incidence of intravascular uptake of contrast medium was compared using the Touhy and Quincke needles under real-time fluoroscopy during lumbar MBB. Injection time, radiation dose, and patient discomfort during lumbar MBB were also compared.
RESULTS: The incidence of intravascular injection was 21.8% (21/102) in the Touhy needle group and 21.2% (22/99) in the Quincke needle group. The odds ratio for the association between the needle types and intravascular injection was 1.1. The injection time, radiation dose, and patient discomfort during lumbar MBB were similar between the Touhy and Quincke needle groups.
LIMITATIONS: This study was performed from L2 to L4 MBB of the unilateral lumbar region. Although the type of needle assigned to the patient was randomized, 3 needles, which are used for 3 levels of MBB, were identical.
CONCLUSIONS: The overall incidence rate of intravascular injection during lumbar MBB was nearly 20% under real-time fluoroscopy for both types of needle. Use of the Touhy needle did not reduce the intravascular injection rate nor the injection time, radiation dose, and patient discomfort.
KEY WORDS: Quincke needle, Touhy needle, intravascular injection, medial branch block







Since this malpractice insurance program officially launched in November 2018, ASIPP has signed up hundreds of providers with an average savings of 30%. This is professional liability insurance tailored to our specialty and will stand up for us and defend our practices.

Norcal Mutual is A-Rated by AM best and is licensed in all 50 states. To read a few important points to keep in mind about the program, including discounts, administrative defense, cyber coverage, aggressive claims handling, and complimentary award-winning risk management CME activities, click here.

ASIPP® has formed a partnership with Henry Schein and PedsPal, a national GPO that has a successful history of negotiating better prices on medical supplies and creating value-added services for independent physicians. Working with MedAssets, PedsPal provides excellent pricing on products like contrast media that alleviate some of the financial pressures you experience today.

ASIPP® is now offering our members the benefit of a unique revenue cycle management/ billing service.

We have received a tremendous amount of interest in the ASIPP® billing and coding program.

Click here to learn more about the negotiated rate for practices and more!
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