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. 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. The Plan denied your request. The Plan 
says the enrollee does not meet the Medicare coverage criteria. 
 
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. 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. Our 
reviewer says that that facet joint interventions do not meet the Medicare criteria. Our physician reviewer found according to the coverage criteria, "after the patient has had at least two (2) medically reasonable and necessary 
diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) 
pain (with the duration of relief being consistent with the agent used)."  You have had multiple therapeutic 
MBB/facet joint injections with no documented plan to proceed to radiofrequency ablation. There is no 
documentation of why you are not a candidate for radiofrequency ablation such as established spinal 
pseudoarthrosis or implanted electrical device. The review has determined that you do not meet the coverage 
criteria detailed in the LCD. 
 
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. 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 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