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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 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:
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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).
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).
You can find this rule in the 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.