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 that Indications:
 Patient must have history of at least 3 months of moderate to severe pain with functional impairment and
pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as
tolerated).
 Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with
radiculopathy or neurogenic claudication.
 There is no non-facet pathology that could explain the source of the patient's pain, such as fracture, tumor,
infection, or significant deformity.
 Clinical assessment implicates the facet joint as the putative source of pain.
General Procedure Requirements:
 Pre-procedural documentation must include a complete initial evaluation including history and an
appropriately focused musculoskeletal and neurological physical examination. There should be a summary of
pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.
 A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure.
Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of
injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain
assessments. With RF neurotomy, electrode position, cannula size, lesion parameters, and electrical stimulation
parameters and findings must be specified and documented.
 Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed
tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be
reimbursed.
 A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images which
adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in
which using contrast is contra-indicated, such as patients with documented contrast allergies), must be retained
and submitted if requested.
 In order to maintain target specificity, total IA injection volume must not exceed 1.0 mL per cervical joint or
2 mL per lumbar joint, including contrast. Larger volumes may be used only when performing a purposeful
facet cyst rupture in the lumbar spine.
 Total MBB anesthetic volume shall be limited to a maximum of 0.5 mL per MB nerve for diagnostic
purposes and 2ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and
2ml for therapeutic purposes.
 In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or
dexamethasone or equivalents shall be injected during any single injection session.
 Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may
be acceptably performed without steroids.
Provider Qualifications:
Provider Qualifications' requirements must be met. Patient safety and quality of care mandate that healthcare
professionals who perform Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency
Neurotomy are appropriately experienced and/or trained to provide and manage the services. The CMS Manual
System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1
(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) underscores this point and states that "reasonable
and necessary" services must be "ordered and/or furnished by qualified personnel." Services will be considered
medically reasonable and necessary only if performed by appropriately experienced and/or formally trained
providers.
The following training requirement applies only to those providers who have not provided these specific
interventional pain management services on a regular basis (at least two times per month) during the ten years
prior to the effective date of this LCD as may be established by claims billings. A basic requirement of
payment is training and/or credentialing by a formal residency/fellowship program and/or other training
program that accredited by a nationally-recognized body and whose core curriculum includes the performance
and management of the procedures addressed in this policy. Recognized accrediting bodies include only those
whose program accreditation gains the trainee eligibility to sit for a healthcare-related licensing exam or
licensing itself, which in turn allows the licensee to perform these procedures. At a minimum, training must
cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, the technical
performance of the procedure(s) and utilization of the required associated imaging modalities, and the
diagnosis and management of potential complications from the intervention.
The following credentialing requirement applies to all providers of the services addressed in this policy. A
practitioner who works in a hospital or ASC facility at any time should be credentialed by the facility for any
procedure also performed in an office setting.
Diagnostic Facet Joint Injections
 Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false
positive rate of single MBB injections.
 A second confirmatory MBB is allowed if documentation indicates the first MBB produced greater than
80% relief of primary (index) pain and duration of relief is consistent with the agent employed.

 Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be
performed due to specific documented anatomic restrictions.
Therapeutic Injections
 Either intraarticular injections or medial branch blocks may provide temporary or long-lasting or permanent
relief of facet-mediated pain. Injections may be repeated if the first injection results in significant pain relief
(>50%) for at least 3 months. (See Limitations section for total number of injections that may be performed in
one year.)

 Recurrent pain at the site of previously treated facet joint may be treated without additional diagnostic blocks
if greater than 50% pain relief from the previous block(s) lasted at least 3 months.
Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):
 Only when dual MBBs provide greater than 80% relief of the primary or index pain and duration of relief is
consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be
considered.

 Repeat denervation procedures involving the same joint will only be considered medically necessary if the
patient experienced greater than 50% improvement of pain and improvement in patient specific ADLs
documented for at least 6 months.
Limitations of Coverage:
 A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular
injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five
(5) in the lumbar spine.
 For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will
be reimbursed in any calendar year, involving no more than four (4) joints per session, e.g., two (2) bilateral
levels or four (4) unilateral levels.
 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 for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and
clearly documented.
 Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (less
than 80 degrees Celsius), as well as pulsed RF are not covered.

 Intraarticular and/or extraarticular facet joint prolotherapy is not covered.
You can find this information in Medicare's Local Coverage Determination (LCD): Facet Joint Injections,
Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L35936).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com