Florida BCBS Reimbursement and Limitations for Injections

Epidural Injections

The total number of epidural, subarachnoid, or caudal injections (CPT 62310 and CPT code 62311) are limited to three (3) in six (6) months and are billed in addition to CPT code 77003 (fluoroscopy) or CPT code 72275 (epidurography).

Epidural or subarachnoid injections (CPT code 62310, and CPT code 62311) are limited to one (1) per date of service

Epidural or subarachnoid injections (CPT code 62310, and CPT code 62311) cannot be given bilaterally

Epidurography (CPT 72275) is limited to one (1) test in six (6) months.

The total number of transforaminal epidural injections (CPT 64479, CPT 64480, CPT 64483, and CPT 64484) is limited to six (6) in six (6) months.

Transforaminal epidural injections (CPT 64479, CPT 64480, CPT 64483, and CPT 64484) are limited to two (2) per date of service

Transforaminal epidural injections (CPT 64479, CPT 64480, CPT 64483, and CPT 64484) are typically not given bilaterally in one date of service.

Epidural injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.

Sacroiliac Joint Injections

Total number of sacroiliac joint injections is limited to three (3) injections per sacroiliac joint in six (6) months. Sacroiliac joint injections are billed in addition to CPT code 77003 (fluoroscopy) or CPT code 73542 (arthrography)

Allergy Testing and Immunotherapy

BCBS recommends the AAAAI practice guidelines and following are the guidelines with regard to immunotherapy frequency and duration

During the build-up phase, the usual frequency of vaccine administration is 1 – 2 injections per week, at least 2 days apart.

Cluster immunotherapy is two or more injections administered per visit to achieve a maintenance dose more rapidly than with conventional schedules.

Rush immunotherapy schedules can achieve maintenance dose more quickly than weekly schedules, but are associated with an increased risk of systemic reaction.

When maintenance dose is achieved, intervals between injections can be progressively increased as tolerated to 4 – 6 weeks.

Venom immunotherapy (VIT) injections generally are given at weekly intervals.

VIT intervals between maintenance dose injections can increase to 4 weeks the first year of VIT and eventually to every 6 – 8 weeks during subsequent years.

Clinical improvement is usually observed within one (1) year after the patient reaches maintenance dose.

The decision to continue or stop therapy should be made after 3 – 5 years.

Consider discontinuing VIT after 3 – 5 years.

The duration of fire ant immunotherapy has not been clearly established, but most allergists recommend continuing therapy 4 – 5 years.

Limitations

CPT codes 95115, 95117 – 152 total injections within 12 months

CPT codes 95120, 95125 – 100 total doses within 12 months

CPT code 95144 – 156 doses within 12 months (specify number of vials)

CPT code 95165 – 156 total doses within 12 months

CPT codes 95130 – 95134 – 52 total doses within 12 months

CPT codes 95145 – 95149, CPT 95170 – 52 total doses within 12 months OR 40 total doses within 3 months for rapid desensitization

CPT code 95180 – 4 hours for a specific substance

Reimbursement for either a single injection (CPT 95115) or multiple injections (CPT 95117) is limited to one (1) per date of service, when provided by the same physician

Vitamin B-12 Injections

Reimbursement for Vitamin B-12 injections is limited to sixteen (16) injections within a twelve (12) month period. Services in excess of the limitation are subject to medical review of documentation in support of medical necessity. The following information may be required documentation to support medical necessity: physician’s history and physical notes, and laboratory tests reports.

*Services in excess of the limitations shown above may be subjected to medical review of documentation for determination of medical necessity and may require documentation to support medical necessity that includes physician history and physical, radiology study reports, physician progress notes, with documentation of conservative treatment, treatment plan including narrative, and physician operative report.*