Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MBBs for the first two levels. We decided that the Plan does not 
have to pre-approve MBB for a third level.  
 
You asked the Plan to pre-approve medial branch blocks (MBBs) for three levels. You say that you have tried 
acupuncture, manipulation and narcotics. You say that you have not had any relief. You also say that your pain 
started after you broke your hip. The Plan says that the requested MBBs are not medically reasonable or 
necessary. 
 
We decided that the Plan has to pre-approve MBBs for the first two levels.  
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain criteria. 
 
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 MBBs. Our reviewer says that MBBs 
for a third level is not medically necessary. Our physician reviewer found the provided documentation supports 
that the enrollee has trialed physical therapy, acupuncture, and takes Hydrocodone/Acetaminophen for pain. 
The reviewer found the imaging indicates multi-level degenerative disc disease and facet arthropathy. The 
reviewer also found that the guidelines do not allow for more than two levels per session. Therefore, the 
reviewer found that the requested MBB for a third level is not medically reasonable or 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 MBBs have been met. Therefore, we decided that the Plan has to pre-approve 
MBBs for the first two levels.  
 
We also decided that the Plan does not have to pre-approve MBB for a third level. 
 
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 MBB at a third level. Our reviewer says 
that MBBs for a third level is not medically necessary. Our physician reviewer found the provided 
documentation supports that the enrollee has trialed physical therapy, acupuncture, and takes 
Hydrocodone/Acetaminophen for pain. The reviewer found the imaging indicates multi-level degenerative disc 
disease and facet arthropathy. The reviewer also found that the guidelines do not allow for more than two levels 
per session. Therefore, the reviewer found that the requested MBB for a third level is not medically reasonable 
or 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 MBB at a third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MBB for a third level. 
 
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.