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Update October 14, 2022: A letter has been sent today to the Medical Directors of multiple MACs regarding Proposed LCD-Sacroiliac Joint Injections and Procedures. Click here to read the letter

On March 10, 2022, a multidisciplinary evidentiary CAC meeting was held with the collaboration of multiple MACs. To date, NGS, Noridian, WPS, and Palmetto have posted their proposed LCDs. CGS has announced an open CAC meeting, but we are awaiting for their LCD to be posted. First Coast and Novitas did not participate in the evidence development. Consequently, we are not sure if they will be posting a proposed LCD or not.

There are various dates for comment periods, with Palmetto having the first comment period closing date of Oct. 15, 2022. Please look over the LCD.

The policy does not show any major requirement changes, but it does tighten all the requirements, like facet joint injections. However, there is one problematic change related to sacroiliac joint radiofrequency neurotomy. In this proposed policy, this is considered as investigational and not covered.

ASIPP will be sending the comment letter within the comment period. If you would like to comment, please make sure that you comment prior to the deadline.

Again, the comment period on the proposed LCD for Sacroiliac Joint Injections and Procedures (DL39402) through Palmetto ended October 15, 2022. Other Medicare Contractors’ comment closing dates are soon after.

Please see the table on the ASIPP website with the Medicare Contractors, comment period and public meeting dates, links, etc.

Here is the link to submit comments to Palmetto and view the LCD. Click here.

We will continue to update you on the future comment dates and public meetings.

Need to catch up on earning your
CME Credits before 2022 is over?

Here is an excellent opportunity offered by ASIPP to earn
19.5 AMA PRA Category 1 CreditsTM in Chicago, November 11-13
The deadline to receive a discounted room at Palmer House Hilton, Chicago has been extended through October 27th!

Important News! 
 
United Healthcare’s new policy reverses the previous policy with a limit of three (3) epidural injections to the ASIPP recommendation of four (4) procedures per year.  
 
As you know, ASIPP has resolutely advocated for a change in the policy on epidural injection limits of three (3) per year through evidence-based presentations and communication. We first sent a letter on June 21, and they responded on June 27. Since then, we have continued with multiple other correspondences. Consequently, they published the new policy effective November 1, 2022, which now provides coverage for four (4) procedures.
 
Coverage rationale and documentation requirements have also changed somewhat more favorably for physicians. See United Healthcare Policy
 
As a reminder, after much effort and many correspondences on the part of ASIPP, percutaneous adhesiolysis is now covered in all states, following the reversal of noncoverage policies of Noridian and Palmetto. 
 
We are still awaiting the response from Centene in reference to the continuation of the epidural injections when indicated beyond one year. We will keep you posted on the developments. See Letter to Centene. 




Great news! Representatives Larry Bucshon (R-Ind.) and Ami Bera (D-Calif.), are introducing a bill that would prevent a 4.4 percent Medicare physician fee payment cut from taking effect on January 1, 2023, through the introduction of the Medicare Access and CHIP Reauthorization Act of 2015 and associated payment mechanism.

This is the bill we have been requesting from members of the Congress to introduce for some time for the last few months. ASIPP has supported this and ASIPP members have sent over 5,000 letters to Members of the Congress to date.

Representatives Bucshon and Bera are supported in this endeavor by six additional representatives, Kim Schrier M.D. (WA-08), Michael Burgess, M.D. (TX-26), Earl Blumenauer (OR-03), Brad Wenstrup, D.P.M. (OH-02), Bradley Schneider (IL-10), and Mariannette Miller-Meeks, M.D. (IA-02). Together they sent a Request for Information: Medicare Payment System Reform letter to members of Congress. See RFI Letter

Resident/Fellow News and Updates






Young physicians and residents should take advantage of mentorship opportunities to further their careers, according to an Oct. 25 article on the American Medical Association website. 
Here are five tips for finding a physician mentor, per the organization: 

  1. Seek them out: Good mentors in the field can be hard to find once you have finished training. 
  2. Look for variety: Look for mentors who can provide guidance in local fields as well as national, big-picture advice. 
  3. Match the mentor to the situation: Reach out to those who have gone through the same training and programs. 
  4. Do not force it: If a mentor relationship does not work out, find someone who can better speak to your needs. 
  5. Expand the definition: Do not assume that age makes a good mentor; consider a variety of qualifying factors.

REMAINING PART I EXAM DATES THIS YEAR:
November 19 & December 17







Former finance minister Rishi Sunak completed a political comeback Monday, when he was selected prime minister by Britain's ruling Conservative Party, just seven weeks after he was beaten to office by Liz Truss. 

Sunak, 42, officially became prime minister on Tuesday after meeting with King Charles at Buckingham Palace, where he received symbolic permission to take up the role during a ceremony known as the "kissing of the hands."

Sunak is the fifth British prime minister in six years, the third in less than two months. He is Britain's first leader of South Asian descent, its first Hindu prime minister, and the nation's first leader of color. He is the youngest prime minister of modern times.

He won an internal party contest to be the country's new leader following Truss' Oct. 20 resignation. Her tenure was the shortest ever for a British prime minister and was marked by economic turmoil. British voters elect a party, not a specific leader, meaning the ruling party has latitude to change a prime minister without calling an election. Sunak won the party contest after his challenger Penny Mordaunt dropped out of the race. 



Prioritize opioid-sparing techniques, safe disposal methods, and patient education

October is National Substance Abuse Prevention Month. According to CDC data, an average of 207 people died each day from opioid overdoses in the U.S. during the 12-month period ending in April 2021. When opioids are prescribed in the hospital setting, a patient's risk for long-term opioid reliance increases, regardless of whether they had prior exposure to opioids. Patients receiving opioids for short-stay surgeries have a 44% increased risk of long-term opioid use, and over 60% of those receiving 90 days of continuous opioid therapy continue use years later. These figures are staggering, and as medical professionals, we must adapt our practice to help prevent opioid misuse in surgical patients.

Countless medical professionals have witnessed patients become addicted to narcotics after surgery. As clinicians, our goal is to return patients to their normal lives, with as little disruption as possible. A critical component of this is educating patients about options for pain control and the potential risks of opioid use during and after surgery. Reducing opioid use can help enhance recovery, reduce complications, allow patients to resume a normal life more quickly, and improve overall patient satisfaction.

We recommend working with all patients to ensure they are active participants in their own recovery. In our practice, teams across our footprint regularly collaborate with surgeons, nurses, and other clinical providers to develop pathways of care that put the patient at the center. This collaboration is part of a larger care program called Enhanced Recovery After Surgery (ERAS) -- a longstanding, proven pathway of care in surgery, providing significant improvements in the quality of care delivered.


Coffee subtypes and associations with incident arrhythmia, CVD, and mortality. Caffeinated (ground/instant) but not decaffeinated coffee reduced the risk of arrhythmia. Both caffeinated and decaffeinated coffee reduced incident CVD and all-cause and cardiovascular mortality risks. CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio.

Coffee is ubiquitous in most societies, with its main constituent caffeine the most commonly consumed psychostimulant worldwide.1 With increasing public awareness on cardiovascular disease (CVD) prevention, significant interest has focused on modifiable lifestyle risk factors, including the safety of coffee. Historically up to 80% of health practitioners recommend avoiding coffee in patients with CVD.2 This misconception has been challenged by recent observational studies, which not only report the safety but a beneficial effect of coffee intake on incident arrhythmia and CVD prevention.1,3,4 In fact, coffee consumption at 3–4 cups/day is described as moderately beneficial in the prevention of CVD in the 2021 European Society of Cardiology guidelines,5 although no such recommendation was made in the 2019 AHA/ACC guidelines.6


Beneficiaries may spend less on premiums, but care delays are common. Do worse outcomes follow?

From their ads, Medicare Advantage (MA) plans may seem like a low-cost, easy, and efficient way for America's seniors to get healthcare. But Barry, a recently retired software executive, tells a cautionary tale.

When a gastric issue led the 65-year-old (his name has been changed to protect his privacy) to the hospital this summer, a CT and biopsy revealed pancreatic cancer. His oncologist came to his bedside to discuss next steps.

"We'll need to do a PET scan to see if the tumor is localized, and that will determine whether we should do chemo or surgery," he was told. With pancreatic cancer, the oncologist said, "the faster we move, the better."

But the oncologist frowned. Unfortunately, the scan couldn't be scheduled for 3 or 4 weeks.

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 November 2022.
For meeting or exhibitor/sponsor information:
Email Karen Avery at kavery@asipp.org or call 270.554.9412 ext 4210


An undue focus on weight can lead to patient distrust and delayed care


Imagine a sales rep comes to your clinic office to pitch a new gadget to gauge your patients' health. They tell you that it's not nearly as good as the measures you already have. It performs even worse with older people and athletes. It will drive large numbers of patients away, while it worsens symptoms in others. Then the sales rep adds sheepishly, at least it's cheap and easy to use.

Would you buy it? Of course not, who in their right mind would?

Except, that is, if that "new gadget" is a body mass index (BMI) calculator. Then buying it is what most of us in the health professions have already done, usually without questioning. And the consequences are dangerous.

The genesis of BMI as a metric dates back nearly 2 centuries to the work of Belgian mathematician (not physician) Adolphe Quetelet, who had the singular idea to create a quick way to approximate body composition in the society. In the 20th Century, BMI was resurrected as a risk prediction tool for insurance companies. Though BMI was never intended as a measure to be applied to an individual's health, by the 1990s, as panic arose over increasing weights nationwide, Quetelet's metric -- once so obscure that it was known only in the rarefied world of historians of 19th Century mathematics -- became a household word. BMI has now become the organizing principle of a massively sprawling surveillance system and the default tool in society's arsenal in the "war on obesity."



More thought given to use of space inside and outside facilities

Hospital design has evolved since the COVID-19 pandemic began, with hospitals not only changing the way they use their space but also finding more ways to provide high-level care outside the hospital, several health system executives said during a panel discussion sponsored by U.S. News Live.

"The pandemic forced us to change faster than what was imagined before," said Chris Bowe, MHA, senior vice president and COO of Atrium Health-Greater Charlotte (North Carolina) Region. "Instead of 'What could we do?' it became 'What do we have to do?' And many of the spaces that we opened during the height of Delta and Omicron [have since] returned back to their origin."

Responding to Fluctuations
Although the health system still has bed and care spaces that continue to operate under the public health emergency rules, "what seemed extraordinary in the past now has become prepared responses to fluctuations in volumes and needs," he said at the webinar, which was also sponsored by Medxcel, a health facilities maintenance firm. "Some examples of this include expansion of our ICUs and emergency department spaces and teams, meeting surging populations, [dealing with] longer lengths of stay and shifting acuity ... And we expanded our use of virtual critical care and virtual hospitalist services."

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"This is not going to happen overnight," says one state official

Getting the Medicaid program through the period after the COVID-19 public health emergency (PHE) ends -- a time when some Medicaid beneficiaries will lose their eligibility -- will not be easy, Medicaid officials from several states said Tuesday.

"This is not going to happen overnight," Amanda Cassel Kraft, Assistant Secretary for MassHealth at the Massachusetts Executive Office of Health and Human Services, said at a webinar sponsored by the Kaiser Family Foundation. "States have about a year to initiate eligibility renewals, and we've got a whole lot of members to go through the process."

"Part of the balance that we're trying to strike is getting out the message far and wide, and as clearly and simply as we possibly can, about the process and the need for members to respond when they do receive renewals," she said. "But also understand that it's not as if all 2.3 million of our members are going to receive requests to renew their eligibility on day 1 of the end of the PHE and they're all going to be acting at the same time. This is going to be an extended process, and it's going to require an ongoing kind of attention and partnership with our providers, our advocacy organizations, and our community organizations around the state to continue to reach out to members, and for folks to respond to that envelope when it does come, even if that is 7 months into the process."



What experts say about concerning social media posts from the U.K.

Since the beginning of the year when Omicron took hold in the U.S., physicians across the country have reported seeing fewer instances of blood clotting linked to COVID-19.

However, recent social media postings from members of the medical community in the U.K. -- which has served as a harbinger for what's to come in the U.S. throughout the pandemic -- have raised the possibility of a reversal of this trend.

Last week, Graham Lloyd-Jones, MBBS, MRCP, a radiologist with the Salisbury NHS Foundation Trust in the U.K., wrote the following on Twitter, sparking an extended thread from other healthcare professionals: "To all #radiologists. Have you seen the typical #COVID pulmonary vasculopathy on CXR/CT in the last week? We've not seen this since omicron became dominant Feb '22. I'm concerned we have a new variant which causes the same clotting in the lungs as delta/pre-delta."

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 |


Standiford Helm II, MD, Carl Noe, MD, and Gabor Racz, MD


Abstract
BACKGROUND: While the complications of cervical epidural steroid injections have been closely studied, there have been no reports of medullary cord injury, including myelopathy, myelomalacia, or syringomyelia, after these injections. We report here a case of myelopathy progressing to myelomalacia and a case of syringomyelia after properly performed cervical intralaminar epidural steroid injections. 

CASE REPORT: One case was characterized by a long history of advanced cervical spondylosis, the other by a distant history of cervical trauma. In neither case was there any evidence to suggest that the patients were at risk for medullary cord injury.

CONCLUSIONS: Epidural injections can generate clinically significant pressure changes in susceptible patients. Flexion and rotation of the neck should be done if unexpected pain occurs after an injection. These adverse outcomes, while rare, can occur in the absence of any departure from the standard of care on the part of the performing physician.

KEY WORDS: Cervical epidural steroid injection, complications, myelopathy, syringomyelia, case report

| RANDOMIZED EXPERIMENTAL TRIAL |


Najah Elmounedi, PhD, Walid Bahloul, MD, Melek Turki, MD, Raja Amri, PhD, Mourad Aoui, MD, Walid Elbaya, MD, and Hassib Keskes, MD

Abstract
Background: Numerous animal models of intervertebral disc (IVD) degeneration have been proposed in the literature. The rat caudal disc has been used in disc degeneration studies because of its low cost and simplicity. However, no consensus on the size of the needle to be used during this process has been reached, yet.

Objectives: This study aims to select an optimal needle size to establish a reproducible IVD degeneration model.

Study design: This is a randomized, experimental trial.

Setting: Cell therapy and experimental surgery of musculoskeletal system LR18SP1 Lab, The Faculty of Medicine of Sfax, Tunisia.

Methods: The validity was verified by magnetic resonance imaging (MRI), histological, and immunohistochemical examinations.

Results: The MRI, histological, and immunohistochemical examinations showed that a disc that is perforated with a 21G needle degenerated acutely one week after the surgery, while a 29G needle puncture failed to develop disc degeneration. A 25G needle induced progressive degeneration in the IVD.

Limitations: This study was not very long (6 weeks).

Conclusions: We conclude that the size of the needle affects the onset and the progression of disc degeneration; a larger needle size leads to a more extended histological and radiographic degeneration within the IVD and in a relatively short time. Therefore, a 21G needle is an optimal choice to induce rapid degeneration in rats' caudal discs. However, the use of a 29G needle failed to establish a degenerative IVD model, which makes it ideal for IVD injection of drugs, plasmids, and growth factors. A 25G needle may be used to induce gradual degeneration.

Keywords: animal model; caudal spine; different needle sizes; optimal choice; Degenerative intervertebral disc.

| PROSPECTIVE STUDY |


Yuting Zhang, MS, Xiujin Chen, MS, Jiachen Ji, BS, Zhengwei Xu, MD, Honghui Sun, MD, Liang Dong, MD, and Dingjun Hao, MD


Abstract
Background: Percutaneous kyphoplasty (PKP) is an effective treatment for osteoporotic vertebral compression fractures (OVCF). Comparisons of different approaches have previously focused primarily on x-rays. Three-dimensional (3D) computed tomography (CT) enables better imaging evaluation of bone cement distribution.

Objectives: To compare the CT imaging parameters and clinical efficacies of unilateral and bilateral PKP.

Study design: This was a prospective, nonrandomized controlled study.

Setting: Department of Orthopedics from an affiliated hospital.

Methods: Seventy-two single-level OVCF patients who underwent 3D CT between 2018 and 2020 were evaluated prospectively. All patients underwent PKP and were assigned to 2 groups: unilateral PKP and bilateral PKP. Imaging outcomes were assessed by determining the cement volume, leakage, dispersion index, vertebral height (VH) and the cement volume of the noninjected and injected sides. Clinical outcomes were evaluated using the Visual Analog Scale (VAS). The correlations between the bone cement volume or dispersion index and the VAS, VH improvement rate (VHIR), or bone cement leakage were also evaluated.

Results: The mean follow-up time was 17.1 months. The postoperative VH and VAS in both groups were significantly improved (P < 0.05). However, there were no statistically significant differences in the cement volume, leakage or dispersion index, VH, or VAS between the 2 groups. No statistically significant differences in the cement volume or VH were found between the noninjected and injected sides within the unilateral group. The operative time was significantly shorter in the patients who underwent unilateral PKP. Unilateral PKP in which the bone cement did not cross the midline had a higher VAS compared with bilateral PKP. Both the bone cement volume and dispersion index displayed a positive correlation with the VHIR, but no correlation with the VAS or bone cement leakage.

Limitations: This study was limited by the nonrandomized design, small sample size, and short follow-up period.

Conclusions: While unilateral PKP was as effective as bilateral PKP, it had a shorter operation time. However, the bilateral PKP approach might be followed when bone cement is distributed in only one side following the unilateral PKP procedure.

Keywords: bone cement distribution; percutaneous kyphoplasty; Osteoporotic vertebral compression fracture.



ASIPP is now in collaboration with Curi Medical Liability Program


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.
 
Curi is a full-service advisory firm that serves physicians and their practices. Their valued advice is grounded in your priorities and elevated in your outcomes. They are driven by a deep understanding of your specific circumstances in medicine, business, and life. To read a few important points to keep in mind about the program, including discounts, administrative defense, cyber coverage, aggressive claims handling, and complimentary risk management CME activities, visit our website.

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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