Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MBBs at the first two levels. We decided that the Plan does not 
have to pre-approve a MBB at a third level.  
 
You asked the Plan to pre-approve medial branch blocks (MBBs), three levels. You say that two bilateral 
medial branch blocks are medically necessary for the enrollee. You say that the previous request was for three 
levels. You also say that the enrollee needs these blocks at L3-4 and L4-5. The Plan says that the requested 
injections are not medically necessary. 
 
We decided that the Plan has to pre-approve MBBs at the first two levels.  
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria. 
 
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 MBBs. Our reviewer says that medial 
branch blocks (MBBS) at the first two levels are medically necessary. Our physician reviewer found the 
provided documentation supports that the enrollee has had trials of physical therapy (PT) and is doing a home 
exercise program (HEP). Therefore, the reviewer found that two levels of diagnostic MBBs are medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have been met. Therefore, we decided that the Plan has to pre-approve 
MBBs at the first two levels.  
 
We also decided that the Plan does not have to pre-approve a MBB at a third level. 
 
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 MBB at a third level. Our reviewer 
says that medial branch blocks (MBBS) at a third level is not medically necessary. Our physician reviewer 
found the records clearly indicate that one to two levels are allowed per session per spine region. The records 
do not support the need for an MBB at a third level. Therefore, the reviewer found that a diagnostic MBB at the 
third level is not medically reasonable and necessary.  
 
 
 
 
 
 
 
 
 
 
 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 MBB at a third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MBB at a third level. 
 
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.