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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 Facet injections, also known as facet blocks, may be given for diagnostic purposes to determine if the facet joint is the source of suspected spinal pain or for therapeutic purposes to treat facet pain that has been previously established. Imaging findings are of little value in diagnosing facet syndrome. It is usually a diagnosis of exclusion. Clinical signs alone cannot diagnose facet joint-mediated pain, but may be of value in selecting candidates for controlled diagnostic local anesthetic blocks. The response pattern to diagnostic facet joint injections has become the gold standard for diagnosing facet syndrome. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms. 

The facet block procedure is an injection of a local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Please refer to the Local Coverage Article: Billing and Coding: Facet Joint Interventions for Pain Management (A56670), for instruction on reporting these services. 

Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic neck or back pain confirmed as originating in the facet joint's medial branch nerve. 

There are various methods that may be used in performing facet joint denervation. Percutaneous radiofrequency (RF) ablation (rhizotomy) is a minimally invasive procedure done with imaging guidance (fluoroscopy or CT per code descriptor) and involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. Conventional radiofrequency ablation (non-pulsed or continuous) applies thermal energy of typically 80 to 85 degrees Celsius. The terms radiofrequency ablation (RFA) and radiofrequency neurotomy are used interchangeably. Both terms refer to a procedure that destroys the functionality of the nerve using radiofrequency energy. 

Non-thermal methods of denervation include chemical (chemodenervation), low-grade thermal energy (less than 80 degrees Celsius), pulsed RF (PRF), laser neurolysis, and cryoablation. Please refer to the related billing and coding article for proper reporting of these services. 

Covered Indications 

1. Facet Joint Interventions:

Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria: 

Duration of pain of at least three (3) months 
Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability 
Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs (NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated) 
History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication 
Physical examination with documented signs that the facet joint is the primary suspected source of pain 
There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity 

2. Diagnostic Facet Joint Injections: 

The primary indication of diagnostic facet joint injection(s) is to confirm a clinical suspicion of facet syndrome. Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain to establish consistency of results due to high false positive rate of a single MBB injection. 

For the first diagnostic MBB to be considered medically reasonable and necessary, the patient must meet the criteria outlined under indications for facet joint interventions. 
A second confirmatory MBB is considered medically reasonable and necessary when ALL of the following are met: 

The patient meets the criteria for the first diagnostic block; AND 
After the first diagnostic MBB, there must be a positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and activities of daily living (ADLs), or a change in technique can be considered. 
Note: Intraarticular facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks cannot be performed due to specific documented anatomic restrictions. These restrictions must be clearly documented in the medical record and made available upon request. 

3. Therapeutic Facet Joint Injections: 

The first therapeutic facet joint injection is considered medically reasonable and necessary if the patient has had two (2) medically reasonable and necessary diagnostic MBBs with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs. 
Subsequent therapeutic injections at the same anatomic site are considered medically reasonable and necessary when the patient has had at least 50% pain relief for at least three (3) months from the prior therapeutic injection. Repeat medically reasonable and necessary therapeutic injections at the same site of a previously treated facet joint may be done without additional diagnostic MBBs. 

4. Facet Joint Denervation: 

The thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows:

Initial thermal RF ablation: 
After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs; 

OR 

After the patient has had at least one (1) medically reasonable and necessary therapeutic injection that provided at least 50% pain relief for at least three (3) months. 
Repeat thermal facet joint RF ablation at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 50% improvement in pain for at least six (6) months. 

The following are considered not reasonable and necessary and therefore will be denied: 

1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and necessary. This includes facet joint interventions done without any guidance, performed under ultrasound guidance, or with Magnetic Resonance Imaging (MRI). Please refer to LCD L35094 Services That Are Not Reasonable and Necessary, for information on paravertebral facet injections with ultrasound guidance. 
2. Intraarticular and extraarticular facet joint prolotherapy are considered not reasonable and necessary. 
3. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are considered not reasonable and necessary. 
4. General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Please refer to LCD L35049 Monitored Anesthesia Care for additional information. Frequent reporting of these services together may trigger focused medical reviews. 
5. It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar spinal regions. Therefore, the routine performance of facet joint interventions (both diagnostic and therapeutic) to both spinal regions may trigger focused medical review. 
6. It is not routinely necessary for multiple blocks (e.g., epidural block, sympathetic block) to be provided to a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or at different level[s]) must be clearly documented in the medical record. For example, performance of both paravertebral facet joint injection(s) and a transforaminal epidural injection (EI) at the same spinal level at the same encounter would not be expected unless a synovial cyst is compressing the nerve root. In this situation, EI may provide relief for the radicular pain while the facet cyst rupture allows nerve root decompression. For additional information on epidural injections, please refer to LCD L36920 Epidural Injections for Pain Management. Frequent reporting of multiple blocks on the same day may trigger focused medical review. 

You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.