Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item ifregular Medicare would pay for it in this case. You can find this rule at 42 CFR 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 411.15 and 411.15(o).The rules say that there are certain covered indications for Facet Joint Interventions and Diagnostic Facet Joint Injections.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 deformityThe rules say that primary indication of diagnostic facet joint injection(s) is to confirm a clinical suspicion of facet syndrome. Dual medial branch block (MBBs) are necessary to diagnose facet pain to establish consistency of results due to high false positive rate of a single MBB injection.For the first diagnostic MBB to be considered medically reasonable and necessary, the patient must meet the criteria outlined under indications for facet joint interventions.A second confirmatory MBB is considered medically reasonable and necessary when ALL of the following are met:-The patient meets the criteria for the first diagnostic block; AND-After the first diagnostic MBB, there must be a positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and activities of daily living (ADLs), or a change in techniquecan be considered.Note: Intraarticular facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks cannot be performed due to specific documented anatomic restrictions. These restrictions must be clearly documented in the medical record and made available upon request. You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).