Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Indications 
 
    Patient must have a history of at least 3 months of moderate to severe pain with functional impairment and 
the pain is inadequately responsive to conservative care such as non-steroidal anti-inflammatory drugs 
(NSAIDs), acetaminophen and/or physical therapy (as tolerated). 
 
    The pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with 
radiculopathy or neurogenic claudication. 
 
    There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, 
infection or significant deformity. 
 
    Clinical assessment implicates the facet joint as the putative source of pain. 
 
General Procedure Requirements: 
 
    Pre-procedural documentation must include a complete initial evaluation including history and an 
appropriately focused musculoskeletal and neurological physical examination. There should be a summary of 
pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain. 
 
    A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. 
Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of 
injections, drugs and doses with volumes and concentrations, as well as pre and post-procedural pain 
assessments. With RF neurotomy, electrode position, cannula size, lesion parameters and electrical stimulation 
parameters and findings must be specified and documented. 
 
    Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed 
tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be 
reimbursed. 
 
    A hard (plain radiograph with conventional film or specialized paper) digital copy image or images which 
adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in 
which using contrast is contra-indicated, such as patients with documented contrast allergies) must be retained 
and submitted if requested. 
 
    In order to maintain target specificity, total intra-articular (IA) injection volume must not exceed 1.0 ml per 
cervical joint or 2 ml per lumbar joint, including contrast. Larger volumes may be used only when performing a 
purposeful facet cyst rupture in the lumbar spine. 
 
    Total MBB anesthetic volume shall be limited to a maximum of 0.5 ml per MB nerve for diagnostic 
purposes and 2 ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and 
2 ml for therapeutic purposes. 
 
    In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or 
dexamethasone or equivalents shall be injected during any single session. 
 
    Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may 
be acceptably performed without steroids. 
 
Provider Qualifications 
Provider Qualification requirements must be met. Patient safety and quality of care mandate that healthcare 
professionals who perform facet joint injections, medial branch blocks and facet joint radiofrequency 
neurotomy are appropriately experienced and/or trained to provide and manage the services. Services will be 
considered medically reasonable and necessary only if performed by appropriately experienced and/or formally 
trained providers. 
 
The following training requirement applies only to those providers who have not provided these specific 
interventional pain management services on a regular basis (at least two times per month) during the ten years 
prior to the effective date of this LCD as may be established by claims billings. A basic requirement of 
payment is training and/or credentialing by a formal residency/fellowship program and/or other training 
program that is accredited by a nationally-recognized body and whose core curriculum includes the 
performance and management of the procedures addressed in this policy. Recognized accrediting bodies 
include only those whose program accreditation gains the trainee eligibility to sit for a healthcare-related 
licensing exam or licensing itself, which in turn allows the licensee to perform these procedures. At a 
minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and 
kinetics, the technical performance of the procedure(s) and utilization of the required associated imaging 
modalities and the diagnosis and management of potential complications from the intervention. 
 
The following credentialing requirement applies to all providers of the services addressed in this policy. If the 
practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the 
practitioner must be credentialed to perform the same procedure in the outpatient setting. 
 
Diagnostic Facet Joint Injections 
 
    Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false 
positive rate of single MBB injections. 
    A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief 
of primary (index) pain = 50% as evidenced by documented functional improvement, increased range of 
motion, a decreased requirement for pain medications and duration of relief is consistent with the agent 
employed. 
 
    Intra-articular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be 
performed due to specific documented anatomic restrictions. 
 
Therapeutic Injections 
 
    Either intra-articular or medial branch blocks may provide temporary or long-lasting or permanent relief of 
facet-mediated pain. Injections may be repeated if the first injection results in significant pain relief (= 50%) 
for at least 3 months. (See the Limitations of Coverage section for the total number of injections that may be 
 
performed in one year). 
    Recurrent pain at the site of a previously treated facet joint may be treated without additional diagnostic 
blocks if documentation supports = 50% pain relief from the previous block(s) as evidenced by functional 
improvement, increased range of motion and decreased requirement for pain medications, that has lasted at 
least 3 months. 
 
Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies): 
 
    Facet joint denervation with RF medial branch neurotomy may be considered only when dual MBBs provide 
significant relief of the primary or index pain and duration of relief is consistent with the agent employed (see 
notation above regarding therapeutic blocks). 
    Repeat denervation procedures involving the same joint will only be considered medically necessary if the 
patient experienced = 50% improvement of pain and improvement in patient specific activities of daily living 
(ADLs) that are documented for at least 6 months. 
 
Limitations of Coverage: 
 
    A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular 
injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the 
cervical/thoracic spine and five (5) in the lumbar spine. 
 
    For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will 
be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) 
bilateral levels or four (4) unilateral levels. 
 
    Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular 
facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may 
be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and 
clearly documented. 
 
    Non-thermal RF modalities for facet joint denervation including chemical denervation (alcohol, phenol, 
etc.), laser therapy, cryotherapy, as well as pulsed RF are not covered. 
 
    Intraarticular and/or extraarticular facet joint prolotherapy is not covered. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Injections, 
Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L36471). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.