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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 
 
Facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) 
months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to 
document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior 
element biomechanical pain are: 
 
    The pain does not have a strong radicular component. 
    There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral 
bending of the spine, depending on the orientation of the facet joint at that level. 
 
A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its 
neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a 
specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). It is further noted that there are two (2) facet 
joints at each level, left and right.  
 
During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial 
branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. 
After the injection(s) have been performed, the patient is asked to indulge in the activities that usually 
aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged 
abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment 
may be prescribed in the future. Some patients will have long lasting relief with local anesthetic and steroid, 
others will require a denervation procedure for more permanent relief. Before proceeding to a denervation 
treatment the patient should experience at least a 50% reduction in symptoms for the duration of the local 
anesthetic effect. 
 
Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may 
take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in 
a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat 
the presumptive diagnosis. If the first set of procedures fail to produce the desired effect or to rule out the 
diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of 
this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic or 
lumbar/sacral. 
 
According to ASIPP guidelines, a positive response to the paravertebral facet joint block is noted when a 
greater than 50% relief of pain is obtained. 
  
Limitations 
 
It is not expected that an epidural block, or sympathetic block would be provided to a patient on the same day 
as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage 
will be extended for only one type of procedure during one day/session of treatment unless the patient has 
recently discontinued anticoagulant therapy for the purpose of interventional pain management. 
 
Diagnostic Phase 
 
    Procedures performed during the diagnostic phase should be limited to three (3) levels (whether unilateral or 
bilateral) for each anatomical region as defined in this LCD on any given date of service. 
    A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the 
first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of 
different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the 
incidence of false positive responses due to placebo effect). 
    Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at 
that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known 
reliability and validity that implicate the structure. 
 
Therapeutic Phase  
 
    Other interventional pain management procedures done on the same day as paravertebral facet joint blocks 
should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this 
case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these 
are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures 
contribute to pain generation. 
    The medical record must clearly support both procedures. It is recognized that this is not common and the 
frequency with which these codes are combined will be monitored. Multiple procedure modifiers will apply to 
intraarticular sacroiliac injection. 
 
Paravertebral blocks, facet joint injections, and medial branch blocks per "Current Procedural Terminology 
(CPT)" should be performed utilizing direct visualization with fluoroscopy and documented. Blocks performed 
without the use of fluoroscopy are considered not medically necessary.  
 
Provider Qualifications  
 
The CMS manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, outlines that 'reasonable and necessary' services are 'ordered and furnished by qualified personnel.' 
Services will be considered medically reasonable and necessary only if performed by appropriately trained 
providers. A qualified physician for this service/procedure is defined as follows: A) Physician is properly 
enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an 
accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or 
must reflect equivalent education, training, and expertise endorsed by an academic institution in the United 
States and/or by the applicable specialty/subspecialty society in the United States.  
 
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the 
Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under 
which the item or service is considered reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Paravertebral Facet Joint 
Blocks (L33930). 

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.