Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are coverable when certain 
medical necessity criteria are met.  However, Medicare rules state that tt is not expected that patients will 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not medically necessary. Our physician reviewer found the patient 
states she has neck pain with cervical radiculopathy to bilateral occipital regions, bilateral shoulders, and 
bilateral shoulder blades. She is experiencing stiffness, spasm with restrictive range of motion in cervical spine. 
She has numbness, tingling sensation along with sharp shooting pain and weakness in the bilateral upper 
extremities, but more in her right upper extremity. Her neck pain is rated 7-8/10 on a pain scale. Her axial neck 
pain was treated conservatively over 3 months, but she continues to have axial cervical pain with facet joint 
tenderness. The enrollee's range of motion and rotation is reduced by about 30-40%. She has moderate 
tenderness and tightness and moderate tenderness on cervical facet joints from C3 to C7 bilaterally upon deep 
palpation. Moderate pain was elicited upon flexion, extension, and lateral flexion bilaterally. Some trigger 
points and muscle spasm were identified. Foraminal Compression test was positive (pain was increased upon 
pressing down on the patient's top of head). Spurling's maneuver was positive on the right side (radicular 
symptoms and pain in the right arm, was increased upon pressing down on the patient's top of head when the 
patient's neck was extended and laterally flexed). Bilateral occipital tenderness with radiating pain to posterior 
scalp bilaterally was noted upon deep palpation.  Magnetic Resonance Imaging revealed bulging discs at C3-
C4, C4-C5, C5-C6, and C6-C7.  Conservative treatments have included Percocet, Lyrica, cervical collar, home 
exercise/ stretching.  In addition, the enrollee has low back pain with lumbar radiculopathy, with an average 
pain level of 8-9/10. The low back pain is radiates to her buttocks. The provider has requested bilateral C4-C5 
and C5-C6 facet joint blocks/medial branch blocks (MBBs) and lumbar MBB. In this case, the patient has 
bothcervical and lumbar 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 injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.