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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 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. 
 
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. 
 
    Intra-articular 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 intra-articular 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 (greater 
than 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 equals 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 equals 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, intra-articular 
injections, facet cyst rupture and RF ablations may be performed per rolling 12 month 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 rolling 12 month 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 intra-articular 
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 
 
    Intra-articular 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 (L34995). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.