MAC Decision on Sacroiliac Procedures Bad for Medicare Patients

Five of the seven Medicare Administrative Contractors (MACs) the federal government relies on to administer Medicare payments have issued a final local coverage determination rule involving sacroiliac procedures. A careful analysis suggests the rule is not good for Medicare patients. The American College of Radiology is among a number of professional medical organizations coming out in opposition to the rule.

Implemented in March 2023, the rule greatly limits patient access to most sacroiliac procedures. It completely denies patients access to sacroiliac joint radiofrequency oblation and sacral lateral branch radiofrequency neurotomy. In addition, it severely limits access to sacroiliac joint injections.

Patients suffering from severe back pain associated with the sacroiliac joint will more or less be left with opioids and surgery as their only options when first line treatments do not seem to help. For many patients, neither surgery nor opioids are desirable alternatives.

The Reasoning Behind the Rule

According to a joint statement issued by the MACs, the determination to limit access to sacroiliac procedures is based on a number of factors, including:

● lack of practice standards

● patient selection concerns

● lack of assessment criteria

● treatment frequency concerns

● unclear long-term outcomes.

Despite the contractor’s concerns, numerous studies have shown that sacroiliac interventions do help some patients. Granted, pain relief is normally short-term in nature and only lasts for a few months at a time. But that is far better than putting patients on opioids. Sacroiliac interventions are also significantly less invasive than surgical procedures.

Sacroiliac Joint Injections

Among all the sacroiliac interventions, sacroiliac joint injections are the least invasive and the easiest to perform. They are on the list of options for back pain at the Lone Star Pain Medicine clinic in Weatherford, TX. Lone Star doctors say the injections rely on a combination of steroid medications and pain relievers to bathe the effected joint.

The pain relievers offer an immediate anesthetic effect while the steroid medications reduce inflammation for more long-term pain relief. It is not unusual for a patient to enjoy a few months of pain relief before having to repeat the injections.

The other two sacroiliac interventions, sacroiliac joint radiofrequency oblation and sacral lateral branch radiofrequency neurotomy, offer relief by blocking pain signals to the brain through the use of radiofrequency signals. Neither procedure is as invasive as traditional back surgery but more invasive than joint injections.

What It Means to Patients

So, what does all this mean to patients? It means that most Medicare patients will no longer have access to sacroiliac interventions regardless of the severity of their back pain. When things like physical therapy, cold compresses, and OTC pain medications do not help, they will have to consider surgery or opioids.

If there is any good news in this, it is the fact that MACs operate somewhat independently within their own regions. So although five of them have decided to limit access to the procedures, the other two have not. Patients in those other two regions may still have access to sacroiliac interventions, at least for the time being.

Patients are encouraged to speak with their doctors about the severity of their back pain and how it limits function and quality of life. A combination of therapies may offer enough relief for some patients to avoid surgery or opioid medications. But if not, hard decisions might have to be made.

As for Medicare and its contractors, the decision to stop covering sacroiliac interventions is mystifying. At a time when there is such a high priority on reducing opioid prescriptions, taking away a proven treatment that would do just that makes little sense.

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