Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of diagnostic facet injections (64493, 64494). We decided 
that the Plan does not have to pre-approve a diagnostic facet injection at a third level (64495).  
 
You asked the Plan to pre-approve diagnostic facet injections at 3 levels (64493, 64494, 64495).. You say that 
the requested services are a medical necessity for the enrollee. The Plan says that the request is not medically 
necessary. 
 
We decided that the Plan has to pre-approve 2 levels of diagnostic facet injections (64493, 64494).  
 
The Plan follows Medicare rules. The 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 criteria 
enumerated in the Medicare rules section of this letter. 
 
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 2 levels of diagnostic facet injections 
(64493, 64494). Our reviewer says that the request for 2 levels of diagnostic facet injections is medically 
reasonable and necessary. Our physician reviewer found that the enrollee has trialed physical therapy and had a 
recent epidural steroid injection which provided 50 percent pain relief. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 levels of diagnostic facet injections (64493, 64494) have been met. Therefore, 
we decided that the Plan has to pre-approve 2 levels of diagnostic facet injections (64493, 64494).  
 
We also decided that the Plan does not have to pre-approve a diagnostic facet injection at a third level 
(64495). 
 
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. 
 
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 diagnostic facet injection at a third 
level (64495). Our reviewer says that a third level of diagnostic facet injections is not medically reasonable and 
necessary in this case. Our physician reviewer found the request for a third level exceeds the utilization limit of 
the rules. There is no documentation as to why this limit should be exceeded.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a diagnostic facet injection at a third level (64495) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a diagnostic facet injection at a third level 
(64495). 
 
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.