Appeal type: unknown
Decision: unknown

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 1. Facet Joint Interventions:Facet JointInterventions 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) monthsPain 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 disabilityDocumented 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 claudicationPhysical 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 deformity2. 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 anatomicrestrictions. These restrictions must be clearly documented in the medical record and made available upon request.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 1. Facet Joint Interventions:Facet JointInterventions 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) monthsPain 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 disabilityDocumented 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 claudicationPhysical 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 deformity2. 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 anatomicrestrictions. 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 fromthe 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 radiofrequencydestruction 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; ORAfter 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. LimitationsThe following are considered not reasonable and necessary and therefore will be denied: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.Intraarticular and extraarticular facet joint prolotherapy are considered not reasonable and necessary.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.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.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.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 themedical 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.