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 1. Facet Joint Interventions: 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: Duration of pain of at least three (3) months Pain 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 disability Documented 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 claudication Physical 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 deformity Limitations The following are considered not reasonable and necessary and therefore will be denied: 1. 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. 2. Intraarticular and extraarticular facet joint prolotherapy are considered not reasonable and necessary. 3. 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. 4. 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. 5. 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. 6. 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 the medical 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.