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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 covered indications for facet joint interventions include:
A. Facet Joint Interventions:
- Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration.
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:
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale; AND*
2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated); AND
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst); AND
4. 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.
- *Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).
B. Diagnostic Facet Joint Injection Procedures (IA or MBB):
The primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet syndrome. Intraarticular (IA) facet block(s) are considered medically reasonable and necessary as a diagnostic test only if MBB cannot be performed due to specific documented anatomic restrictions or there is an indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented in the medical record and made available upon request.
Diagnostic procedures should be performed with the intent that if successful, a RFA procedure would be considered the primary treatment goal at the diagnosed level(s).
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic procedure.
1. An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when the patient meets the criteria outlined under the indications for facet joint interventions.
2. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet BOTH of the following criteria:
- The patient meets the criteria for the first diagnostic procedure; AND
- After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used).
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure.
C. Therapeutic Facet Joint Injection Procedures (IA):
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet ALL of the following criteria:
-
1. The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used); AND
2. Subsequent therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; AND
3. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device) is in the medical record.
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.
D. Facet Joint Denervation:
An initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used).
Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.
Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.
E. Facet Cyst Aspiration/Rupture
Intra-articular facet joint injection performed with synovial cyst aspiration is considered medically reasonable and necessary when BOTH of the following criteria are met:
1. Advanced diagnostic imaging study (e.g., MRI/CT/myelogram) confirm compression or displacement of the corresponding nerve root by a facet joint synovial cyst; AND
2. Clinical and physical symptoms related to synovial facet cyst are documented in the medical record.
Frequency limitation: Cyst aspiration/rupture may be repeated once and only if there is 50% or more consistent improvement in pain for at least three (3) months.
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (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.