Denials are rising across healthcare, but pain management practices are feeling this pressure more than most. High-dollar procedures, complex payer rules, strict medical-necessity requirements, and rapidly changing LCDs all make pain claims more vulnerable. And when denials happen, they hurt — financially, operationally, and clinically.
At PainMed-PA, one thing is clear: most denials are predictable. And if they’re predictable, they’re preventable.
This blog breaks down the top denial trends in interventional pain management for 2025 and concludes with practical steps—and a smarter way—to get ahead of payer behavior.
Missing or Invalid Prior Authorization
This remains the #1 denial for high-value pain procedures.
Commonly denied CPTs:
• 63650 – SCS trial lead placement
• 64483 – Lumbar transforaminal injection
• 64635 – Lumbar/Sacral RF ablation
• 64625 – SI joint RF
• 22869/22870 – Generator/lead revision or removal
Why these denials occur:
• Authorization not obtained before the procedure
• Auth expired before the date of service
• Wrong CPT code approved (single vs multi-level, etc.)
• Payer required imaging or conservative care documentation that wasn’t submitted
2025 shift:
Payers are now demanding conservative care documentation + imaging studies even for repeat procedures. This means practices must track not just whether an auth exists, but whether it meets the payer’s new criteria.
Lack of Medical Necessity or Insufficient Documentation
This is the second biggest denial category and one that is growing fast.
Commonly denied CPTs:
• 64633–64636 – RF Ablations (facet/medial branch)
• 64490–64495 – Facet injections
• 63650 / 63685 – SCS trial and implantation
• 20552 / 20553 – Trigger point injections
Triggers for these denials:
• Missing proof of failed conservative care (PT, meds, etc.)
• No diagnostic imaging supporting the diagnosis
• Repeated injections or RF without documenting functional improvement
• Notes don’t clearly state the pain generator or prior treatment failures
2025 shift:
MACs and commercial payers tightened LCDs. There are now stricter timelines between procedures and higher documentation expectations. This is especially true for RFs and SCS.
Incorrect or Missing Modifiers
Modifier-related denials continue to be a major source of preventable revenue loss.
Common modifier mistakes:
• -50 (bilateral)
• -59 or -XS (distinct procedural service)
• -LT / -RT (laterality)
• -22 (increased procedural services)
Examples:
• 64635 billed without the correct bilateral modifier
• 64483 billed twice without indicating levels
• Missing -59 on 77003 (fluoro) when billed with injections
2025 shift:
Payers are applying CCI edits more aggressively and expect documentation to justify every modifier. Multi-level and bilateral procedures are under closer review.
Frequency Limit Exceeded
Pain procedures, especially injections, are heavily frequency-regulated.
Affected procedures:
• Facet injections: 64490–64495
• SI joint injections: 27096
• Trigger point injections: 20552/20553
• Epidural injections: 62321, 64483
Why these get denied:
The same issues from modifiers often overlap here: repeated levels, repeated dates, or billing patterns that exceed payer allowances.
2025 shift:
Practices need EHR alerts to flag frequency risks before the case gets scheduled or authorized.
Bundled or Inclusive Services Billed Separately
Many services, especially imaging and guidance, are bundled into pain procedures.
Common denial patterns:
• 77003 (fluoro) denied when bundled into injections
• 95873/95874 (EMG guidance) denied when included in neurostim procedures
• 64493 denied with 64633 on the same date without proper unbundling modifiers
2025 shift:
Both CMS and commercial payers aggressively enforce bundling. Claims often need modifier -59 or -XU with clear documentation justification.
Non-Covered or Experimental Procedures
Regenerative and advanced therapies continue to face tight coverage restrictions.
Commonly denied:
• PRP injections (0232T)
• Stem cell therapies
• Certain peripheral nerve stimulator codes (64555, 64575)
• Off-label neurostimulation applications
How to protect your practice:
• Always check the payer policy or LCD
• Use ABNs for Medicare patients
• Communicate expected out-of-pocket costs to patients
These denials often aren’t reversible which makes front-end clarity essential.
Incorrect Place of Service or Provider-Type Issues
Less frequent, but still significant.
Common issues:
• POS code doesn’t match documentation (11 vs 22 vs 24)
• Billing provider not credentialed for that payer or procedure
• PA/NP billing without meeting incident-to requirements
This is especially common in hospital-based or ASC settings where workflows involve multiple teams.
How Pain Practices Can Reduce Denials in 2025
Automate real-time eligibility and prior-auth tracking
Manual tracking is no longer enough, especially when payers are modifying policies mid-year.
Use documentation templates tied to payer policies
Checklist-driven templates help providers document:
• Conservative care
• Imaging
• Functional improvement
• Pain generators
• Prior procedure outcomes
Train teams on modifiers and pain-specific CCI edits
This prevents the most avoidable (and costly) coding denials.
Audit denials by CARC/RARC codes
Break them down by:
• Payer
• Procedure
• Reason
This allows you to see patterns before they become revenue leaks.
Crosswalk high-denial CPTs with auth and documentation workflows
Ensures providers and schedulers know the exact requirements for common high-risk procedures.
Use AI tools (like Mainer.Ai) to flag at-risk claims before submission
This is not the future: it is now. AI can predict denial risk and highlight documentation gaps before payers ever see the claim.
Why This Matters
Denials are expensive not just in lost revenue, but in wasted staff time and delayed patient care.
Pain practices that treat denials as a data problem and not just a billing task recover faster, prevent recurrences, and protect margins.
And tools like PainMedPA’s expertise combined with Mainer.Ai’s intelligence help practices stay ahead even as payers raise the bar year after year.
The Smarter Way Forward: PainMed-PA + Mainer.Ai
PainMed-PA delivers the specialty billing expertise pain practices need.
Mainer.Ai brings the world’s first pain-management–focused AI model to your revenue cycle.
Together, they help you:
• Reduce denials
• Improve documentation quality
• Strengthen coding accuracy
• Automate revenue cycle intelligence
• Maximize revenue per procedure
FAQs
1. Why do high-dollar pain procedures face disproportionately more denials?
Because payers flag them as high-risk for overutilization. Procedures like RF ablations, SCS trials, and multi-level injections require stronger proof of medical necessity, more detailed documentation, and stricter adherence to LCDs. Even small gaps—like missing imaging or unclear functional improvement—can trigger denials that wouldn’t occur for lower-cost services.
2. Why are repeat procedures harder to get approved now?
Payers now expect clear evidence that prior interventions helped. Without documented functional improvement or updated conservative care notes, repeat procedures—especially RF and epidural injections—are increasingly denied, even if clinically justified.
3. Why do modifier errors lead to such significant revenue loss?
Modifier errors often occur on procedures with the highest reimbursement value. A missing -50 or -59 can cause both the base and add-on lines to deny, multiplying the revenue impact. These denials are preventable but costly, making modifier accuracy a critical priority.
4. Why are bundled-service denials increasing even when coding hasn’t changed?
Because payers continue to tighten their enforcement of NCCI edits. Some adjust their bundling rules mid-year, meaning combinations that previously paid may suddenly deny. Without timely visibility into these changes, practices get caught off-guard.
5. What’s the biggest hidden cause of denials that practices tend to overlook?
Workflow misalignment between scheduling, clinical documentation, and billing.
For example:
- Scheduling secures a prior auth but not for the correct levels
- Providers perform bilateral procedures but omit laterality in the notes
- Billing assumes conservative care is documented when it isn’t
These disconnects create denials even when every team is doing its best.
6. How do denials impact patient experience, not just revenue?
Denied claims delay treatments, disrupt care plans, and can leave patients facing unexpected bills. Frequent denials erode patient trust in the practice—even when the clinical care itself is excellent—because they create friction, confusion, and delays.
7. How does Mainer.Ai change denial prevention compared to traditional RCM tools?
General RCM tools operate at a surface level. Mainer.Ai, trained specifically on pain-management claim patterns, identifies:
- Missing documentation
- Incorrect modifiers
- Risky CPT combinations
- Prior-auth gaps
- Frequency-limit conflicts
before claims are submitted.
This shifts the practice from reactive denial management to proactive, specialty-aligned prevention, which traditional systems simply aren’t built for.
If you’re ready to reduce denials, increase collections, and bring predictability back to your revenue cycle, our team can help.
Schedule a review with our team at PainMed-PA and Mainer.Ai. Call us today on (512) 868-1762.
Let’s uncover where denials are coming from—and stop them before they reach your billing queue.