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Lumbar epidural injections

Date: May 5, 2021

Question:

Our pain clinic providers see patients who have chronic lumbar pain with radiculopathy and also documentation of lumbar spondylosis. We are using the combination code (M4726) for lumbar spondylosis and radiculopathy and routinely get denied because of coverage under ART 57203. We have tried appealing these without any resolution. Under the coverage documents we have multiple things that would be considered covered if we were allowed to code them out separately (low back pain, lumbar radiculopathy, etc.). Any suggestions on the scenario above in order to get reimbursed? Would it be common to have these conditions (lumbar spondylosis and radiculopathy) not related to each other to support coding them out separately (if documentation supported)?

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