Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions

Facet-joint denervation is a procedure that physicians use to treat neck or back pain caused by arthritis in or injury to the facet joints in the spine. To address inappropriate billing for and overuse of spinal facet-joint denervation for pain management, the Medicare Administrative Contractors (MACs) developed two limitations of coverage. One of the coverage limitations, in place in 11 of the 12 MAC jurisdictions, allowed physicians to be reimbursed, during a 12-month period, for a maximum of 2 facet-joint denervation sessions per beneficiary for each covered spinal region: (1) the lumbar region (lumbar spine) and (2) the cervical and thoracic regions (cervical/thoracic spine). The other coverage limitation allowed physicians to be reimbursed for a maximum of 4 or 10 facet joints per denervation session, depending on the MAC jurisdiction. A prior Office of Inspector General (OIG) audit found that MACs that limited coverage to five facet-joint injection sessions related to the lumbar and cervical/thoracic spines during a rolling year had improperly paid physicians $748,555 for sessions that exceeded this coverage limitation from January 1, 2017, through May 31, 2019. Therefore, we conducted this audit to determine whether Medicare made improper payments from January 1, 2019, through August 31, 2020 (audit period), for selected facet-joint denervation sessions in the MAC jurisdictions that had coverage limitations.