Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. Injection(s), diagnostic or 
therapeutic agent paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 
guidance (fluoroscopy or CT), lumbar or sacral; single level, an introduction/injection of anesthetic agent 
(nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches. 
 
You asked the Plan to pre-approve facet joint interventions. The Plan denied your request. The Plan says the 
Medicare criteria for medical necessity has not been met. 
 
The Plan follows Medicare rules. 
 
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 facet joint interventions. Our reviewer 
says that facet joint interventions do not meet the Medicare criteria. Our physician reviewer found that the 
enrollee is a 55-year-old female with chronic neck and back pain status post a fall in 2005. The pain radiates 
across her back bilaterally and down the left leg. She requested a repeat injection for the pain across her low 
back. Her past surgical history includes lumbar spine surgery 2006 (status post-laminectomy syndrome), 
epidural steroid injections 2019, lumbar facet blocks on June 4, 2021. Per the July 7, 2021 visit note, the 
lumbar facet block done on June 4, 2021 only provided 30% pain relief for about a week. She has tried 
Percocet, Gabapentin, Celebrex and Zanaflex. Her reported pain score is 7/10. Bending and stooping, changing 
from sitting to standing, lifting or carrying heavy or small loads and lying on her back increase her pain. Her 
pain interferes with her daily chores, employment, exercise, sleep, walking and relationships. Physical exam of 
the lumbar spine done on January 28, 2022 is positive for focal tenderness to the bilateral paravertebral 
musculature. Straight leg raise test is negative bilaterally. Facet loading is positive bilaterally. Physical exam 
was the same at the October 26, 2021, and August 26, 2021 visits as well. The enrollee's lumbar MRI on  
July 9, 2021 revealed scoliosis with multilevel degenerative changes and mild anterolisthesis of L4 on L5. 
There is mild spinal canal stenosis at L4-L5. Multi-level bilateral mild to moderate neuroforaminal narrowing. 
She is requesting repeat lumbar facet injection as she states her bilateral low back pain is worse at this time. As 
noted above the previous lumbar facet injection only provided 30% pain relief for a week. In addition, she 
currently has pain that radiates down her left leg. There is no indication in the progress notes, the radicular pain 
has been treated since 2019. The request is for repeat L3-L5 facet joint blocks. The documentation does not 
meet the Medicare LCD criteria. In this case, the enrollee has radiculopathy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions. Injection(s), diagnostic or therapeutic agent 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level, an introduction/injection of anesthetic agent (nerve block), diagnostic or 
therapeutic procedures on the paravertebral spinal nerves and branches.