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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 joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are:-The pain does not have a strong radicular component.-There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). It is further noted that there are two (2) facet joints at each level, left and right.During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future. Some patients will have long lasting relief with local anesthetic and steroid, others will require a denervation procedure for more permanent relief. Before proceeding to a denervation treatment the patient should experience at least a 50% reduction in symptoms for the duration of the local anesthetic effect.Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fail to produce the desired effect or to rule out the diagnosis, the provider should thenproceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracicor lumbar/sacral.According to ASIPP guidelines, a positive response to the paravertebral facet joint block is noted when a greater than 50% relief of pain is obtained.You can find this rule in the Local Coverage Determination (LCD): Paravertebral Facet Joint Block (L33930).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.