Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of facet joint injections. We decided that the Plan does not 
have to pre-approve 1 level of a facet joint injection.  
 
You asked the Plan to pre-approve 3 levels of facet joint injections (64493, 64494, 64495). You say that the 
services are necessary. The Plan says that based on the documentation provided, coverage criteria have not 
been met. 
 
 
 We decided that the Plan has to pre-approve 2 levels of facet joint injections.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 2 levels of facet joint injections. Our 
reviewer says that the services are medically necessary. Our physician reviewer found first, while facet 
injections are outside of the spinal canal, significant hematoma formation is possible with an international 
normalized ratio (INR) at this level. Second, the utilization limit of no more than 2 levels of diagnostic MBBs 
precludes a third level. Assuming, the INR is corrected, then only 2 levels are medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 levels of facet joint injections have been met. Therefore, we decided that the 
Plan has to pre-approve 2 levels of facet joint injections.  
 
We also decided that the Plan does not have to pre-approve 1 level of a facet joint injection. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 1 level of a facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found first, while facet 
injections are outside of the spinal canal, significant hematoma formation is possible with an international 
normalized ratio (INR) at this level. Second, the utilization limit of no more than 2 levels of diagnostic MBBs 
precludes a third level. Assuming, the INR is corrected, then only 2 levels are medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 1 level of a facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 1 level of a facet joint injection. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.