Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve two cervical/Thoracic Facet Joint Block at two levels. We decided
that the Plan does not have to pre-approve one cervical/Thoracic Facet Joint Block at a third level.
You asked the Plan to pre-approve three cervical/Thoracic Facet Joint Block. You say that the service is
medically necessary. The Plan says that these types of shots can only be given at up to two levels at the same
time.
We decided that the Plan has to pre-approve two cervical/Thoracic Facet Joint Block at two levels.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered
under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a
time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA),
facet cyst ruptures, and RFA ablations that are performed during the same day.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a cervical/Thoracic Facet Joint Block.
Our reviewer says that the member does not meet Medicare criteria for coverage of three sets of shots to be
given at three levels. Our physician reviewer found the LCD limits the utilization to two levels bilaterally.
Only two levels bilaterally are deemed medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of two cervical/Thoracic Facet Joint Block at two levels have been met. Therefore,
we decided that the Plan has to pre-approve two cervical/Thoracic Facet Joint Block at two levels.
We also decided that the Plan does not have to pre-approve one cervical/Thoracic Facet Joint Block at a
third level.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve one cervical/thoracic facet joint blocks.
Our reviewer says that the member does not meet Medicare criteria for coverage of three sets of shots to be
given at three levels. Our physician reviewer found the LCD limits the utilization to two levels bilaterally.
Only two levels bilaterally are deemed medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of one cervical/thoracic facet joint blocks at a third level have not been met.
Therefore, we decided that the Plan does not have to pre-approve one cervical/Thoracic Facet Joint Block at a
third level.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a lette