News to Note – January 2020

• A new local coverage determination (LCD) for percutaneous vertebral augmentation was released in November 2019 from Noridian, a Medicare Administrative Contractor (MAC). And, the last week of 2019 brought the release of a proposed LCD by Novitas. The procedure, usually performed in elderly patients, involves treating pain due to vertebral compression fracture by injecting a cement-like substance with or without balloon expansion to stabilize the vertebrae. In 2009 a New England Journal of Medicine study showed no benefit for pain control both short- and long-term. These findings were reproduced in 2018 in a British Medical Journal study. The proposed Novitas LCD shares many features with the final LCD released by Noridian including:
• The patient’s pain must be quantified using either the Numeric Rating Scale or Visual Analog Scale pain score and the scores must correlate to the requirements specified. Physicians cannot quantify pain as “moderate” or “severe.”
• Decision to proceed with vertebral augmentation must be made by a multidisciplinary team including the referring physician, the physician performing the procedure, a radiologist, and a neurologist, based on a 2017 guideline from the Cardiovascular and Interventional Radiological Society of Europe. Review of this guideline shows that this recommendation is not supported by evidence nor the standard of care in the United States. Unless the radiologist is an interventional radiologist, it is unlikely that they would interact directly with the patient to know the duration or degree of pain nor would they perform a physical examination. Without performing a history and physical examination, they cannot provide an opinion on whether vertebral augmentation is indicated. Likewise, there is no medical necessity for a neurology consultation and evaluation unless there are other issues that warrant it. It is within the realm of the neurosurgeon, orthopedic spine surgeon, or interventional pain management physician to perform a neurologic examination to eliminate other causes of the back pain. 
• CMS had published new versions of the Important Message from Medicare (IM) and Detailed Notice of Discharge (DND) and both have significant changes. For Medicare Advantage (MA) patients, the IM must now indicate the patient’s plan name and toll-free phone number. Most MA cards have at least three phone numbers on the back of the card and the web page for the insurer has completely different numbers. One case manager in Ohio asked CMS about this and CMS said, “the expectation is only that a usable Plan phone number be included, not a specific appeals number.” The DND requires citation of the regulation used to determine hospital care was no longer needed. One used to be present on it…but no longer. The Medicare Outpatient Observation Notice (MOON) has also been updated but the only change is the expiration date at the lower left corner. Thanks, CMS! All forms are required to be used by April 1.