Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve diagnostic MBB of C2-C3. We decided that the Plan does not 
have to pre-approve diagnostic MBB of C3-C4 and C4-C5.  
 
You asked the Plan to pre-approve diagnostic medial branch blocks (MBBs) of C2-C3, C3-C4, and C4-C5.. 
You say that you disagree with the Plan's denial. The Plan says that the requested services are not medically 
necessary. 
 
We decided that the Plan has to pre-approve diagnostic MBB of C2-C3.  
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the following 
criteria:  
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of 
the patients pain, including but not limited to fracture, tumor, infection, or significant deformity.  
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 diagnostic MBB of C2-C3, C3-C4, and 
C4-C5. Our reviewer says the documentation does support that the MBB at C2-C3 is medically reasonable and 
necessary. Our physician reviewer found the enrollee has chronic neck pain. The enrollee has had C4-C5 and 
C3-C4 intra-articular steroid injections with minimal improvement. However, C2-C3 has not been injected and 
it is medically reasonable and necessary to do diagnostic block at that level.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBB of C2-C3, C3-C4, and C4-C5. have been met. Therefore, we 
decided that the Plan has to pre-approve diagnostic MBB of C2-C3.  
 
 We also decided that the Plan does not have to pre-approve diagnostic MBB of C3-C4 and C4-C5. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 diagnostic MBB of C3-C4 and C4-C5. 
Our reviewer says that the documentation does not support that the MBBs at C3-C4 and C4- C5 are medically 
reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain. The enrollee has had 
C4-C5 and C3-C4 intra-articular steroid injections with minimal improvement. If the intra-articular injection 
did not provide substantial relief, then those joints are not the probable pain generators. Therefore, the enrollee 
does not meet criteria for these requested MBBs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBB of C3-C4 and C4-C5 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve diagnostic MBB of C3-C4 and C4-C5. 
 
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 letter.