Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635), and 
destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, each additional facet joint (64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint, and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint. You say that the services are medically necessary. The Plan denied your request. The Plan says the 
requested procedure session will exceed the allowed limit of no more than two (2) sessions per region of your 
spine in a year. A session is defined as all spinal procedures performed on the same date of service. Your neck 
and upper back make up one spinal region, and your lower back and tailbone make up the other spinal region. 
 
The Plan follows Medicare rules. Medicare rules say that it is not expected that patients will routinely present 
with pain in both cervical/thoracic and lumbar spinal regions. Therefore, facet joint interventions (both 
diagnostic and therapeutic) are limited to one spinal region per session. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet 
joint, and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, each additional facet joint. Our reviewer says that the requested 
injections are not medically necessary. Our physician reviewer found according to the coverage criteria; the 
requested procedure session will exceed the allowed limit of no more than two (2) sessions per region of the 
spine in a year. A session is defined as all spinal procedures performed on the same date of service.  In this 
case, the neck and upper back make up one spinal region, and the lower back and tailbone make up the other 
spinal region. Since the prior radiofrequency ablation (RFA) were on January 31, 2022, June 1, 2021, and  
June 28, 2021, the request for right L3-5 RFA would exceed two (2) radiofrequency sessions per rolling  
12 months for the lumbosacral region. The review has determined that requested injections do not meet criteria 
for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint, and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or 
sacral, single facet joint (64635), and destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (64636).