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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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. 
 
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 > 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 >50% pain relief from the previous block(s) lasted at least 3 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 (<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.