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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 state that diagnostic facet joint injections are covered for the following indications:-If, after the first medial branch block (MBB) injection, the patient experiences greater than or equal to 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 greater than or equal to 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.The rules state that thermal medial branch radiofrequency neurotomy are covered for the following indications:-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 &#8805; 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 &#8805; 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 (&#8805; 5-6 months) relief of pain and improvement of function in the past following RF ablation.The rules state that therapeutic facet joint nerve blocks are covered for the following indications:-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 performpreviously 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 3months.-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.You can find these rules in the Local Coverage Determination (LCD) for Facet Joint Injections, Medial Branch Blocks, and Facet Joint RadiofrequencyNeurotomy, L34832. This LCD is effective for services provided on or after December 31, 2020.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plancovers items and services in accordance with Medicare rules