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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 CFR 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 then proceed 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/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495). 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. Limitations It is not expected that an epidural block, or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage will be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. Diagnostic Phase o Procedures performed during the diagnostic phase should be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD on any given date of service. o A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect).
o Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. Therapeutic Phase o Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. o The medical record must clearly support both procedures. It is recognized that this is not common and the frequency with which these codes are combined will be monitored. Multiple procedure modifiers will apply to intraarticular sacroiliac injection. Paravertebral blocks, facet joint injections, and medial branch blocks per "Current Procedural Terminology (CPT)" should be performed utilizing direct visualization with fluoroscopy and documented. Blocks performed without the use of fluoroscopy are considered not medically necessary. You can find this rule in the Local Coverage Determination (LCD): Paravertebral Facet Joint Blocks (L33930) effective January 8, 2019.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.