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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 Indications of Coverage: 
 
    At least 3 months of moderate to severe pain with functional impairment inadequately responsive to 
conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated). 
    Predominant axial pain that is not associated with radiculopathy or neurogenic claudication. 
    Absence of non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor, 
infection, or significant deformity. 
    Clinical assessment that implicates the facet joint as the putative source of pain. 
 
General Procedure Requirements: 
 
    Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed 
tomographic (CT) guidance. 
 
Diagnostic Facet Joint Injections: 
 
    If, after the first MBB injection, the patient experiences = 80% relief of their primary (index) pain, lasting a 
time period consistent with the local anesthetic used, the patient may undergo a second, confirmatory 
MBB.Since the technique of MBB relies on the patient's perception of pain relief to establish the diagnosis, the 
patient must have sufficient pain immediately prior to the injection (generally = 3/10 NPRS) to be able to 
detect significant improvement following the injection. Additionally, provocative maneuvers or positions 
which normally exacerbate index or typical pain must be determined before the injection. 
 
Thermal Medial Branch Radiofrequency Neurotomy: 
 
    If adequate, but short term, pain relief occurs following MBB facet joint injections (see Diagnostic Facet 
Joint Injections), RF neurotomy may be a reasonable treatment option. Thermocoagulation with radiofrequency 
energy may achieve long-lasting pain relief via axonotmesis of the sensory afferent medial branch nerve. 
    Dual MBBs are the ideal prognostic test to select patients for thermal RF neurotomy. 
    Only when dual MBBs provide equal to 80% relief of the primary or index pain, with ability to perform 
previously painful movements consistent with the expected physiological effects of the agents utilized RF 
medial branch neurotomy be considered. 
    Repeat denervation procedures involving the same joint for the same region will only be considered 
medically necessary if the patient experienced = 50% improvement of pain and improvement in patient specific 
ADLs documented for at least 5-6 months. 
    Repeat RF neurotomy to treat recurrent facet joint pain in a patient who has failed other conservative 
measures may be covered without repeating MBB injections if the patient has experienced significant and 
prolonged (= 5-6 months) relief of pain and improvement of function in the past following RF ablation. 
 
 
 
 
 
Therapeutic Intraarticular (IA) Facet Injections: 
 
    Emerging evidence suggests that benefit from palliative care with IA injections may accrue in some patients 
and is potentially Medicare reimbursable. There is additional limited evidence that facet joint cyst rupture 
might be effective in a limited number of patients and is potentially Medicare reimbursable. 
 
Therapeutic Facet Joint Nerve Blocks: 
 
    When dual MBBs provide greater than 80% relief of the primary or index pain consistent with the expected 
physiological effects of the agents utilized index pain with ability to perform previously painful movements, 
consistent with the expected physiological effects of the agents utilized, followed by at least 50% improvement 
for 6 weeks with pain and function, therapeutic facet joint nerve blocks may be considered. 
    Repeat therapeutic facet joint nerve block procedures involving the same joint or the same region will only 
be considered medically necessary if the patient experienced greater than 50% improvement of pain and 
improvement in patient specific ADLs documents for at least 2? to 3 months. 
    Repeat therapeutic medial branch blocks to treat recurrent facet joint pain in patient who has failed other 
conservative measures may be covered without repeating MBB injections if the patient has experienced 
expected or prolonged relief of pain with improvement in function (2? to 3 months) in the past following 
therapeutic facet joint injections. 
 
Provider Qualifications: 
 
The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 
(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that "reasonable and necessary" services 
are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and 
necessary only if performed by appropriately trained providers. 
 
Patient safety and quality of care mandate that healthcare professionals who perform Epidural Steroid 
Injections are appropriately trained and/or credentialed by a formal residency/fellowship program and/ or are 
certified by either an accredited and nationally recognized organization or by a post-graduate training course 
accredited by an established national accrediting body or accredited professional training program. If the 
practitioner works in a hospital facility at any time an/or is credentialed by a hospital for any procedure, the 
practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, 
training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well 
as proficiency in diagnosis and management of disease, the technical performance of the procedure and 
utilization of the required associated imaging modalities. 
 
Limitations of Coverage: 
 
    Facet joint nerve injections for the treatment of acute, non-recurrent neck or back pain 
    New onset radiculopathy precludes coverage of facet blockade except radicular pain caused by a facet joint 
synovial cyst in the lumbar spine. 
    Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be 
performed due to anatomic restrictions. 
    A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular 
injections, or facet cyst rupture and RF ablations may be performed per 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) joints bilaterally thermal 
RF sessions will be reimbursed in any calendar year, involving no more than four (4) joints per session. 
 
 
    Repeat neurotomy procedures involving the same joint will only be considered medically necessary when 
the patient had equal to 50% improvement of pain and documented improvement in patient specific ADLs 
documented for at least 6 months. 
    Repeat therapeutic facet joint or medial branch injections involving the same joint will only be considered 
medically necessary when the patient had equal to 50% improvement of pain and improvement in patient 
specific ADLs for at least 3 months. 
    Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular 
facet joint injections or medial branch blocks and are therefore not 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, low grade thermal energy ( 
    Intraarticular or extraarticular facet joint prolotherapy is not covered. 
 
    Frequency with criteria 
 
        Two diagnostic injections are allowed per region irrespective of the joints injected with maximum of 2 
joints allowable per session per region. 
        No more than 4 therapeutic facet joint nerve blocks per year are reimbursable with 2 levels per region, per 
session after the appropriate documentation of 80% improvement with diagnostic blocks for the duration of the 
local anesthetic, and with a total relief and improvement of at least 50% of 6 weeks (including greater than 
80% relief and greater than 50% relief). 
        Two radiofrequency neurotomies per year involving 2 joints per region per session may be performed 2 
times a year with appropriate documentation of relief with dual MBBs and 5 to 6 months of pain relief and 
functional improvement after a session. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Injections, 
Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34832). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.