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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.
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:
o Duration of pain of at least three (3) months;
o 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;
o 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);
o History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not
associated with radiculopathy or neurogenic claudication;
o Physical examination with documented signs that the facet joint is the primary suspected source of
pain;
o 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
deformity.
2. Diagnostic Facet Joint Injections:
The primary indication of diagnostic facet joint injection(s) is to confirm a clinical suspicion of facet syndrome.
Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain to establish consistency of results due
to high false positive rate of a single MBB injection.
o 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.
o A second confirmatory MBB is considered medically reasonable and necessary when ALL of the
following are met:
o
&#9642; The patient meets the criteria for the first diagnostic block; AND
&#9642; 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 technique can 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.
3. Therapeutic Facet Joint Injections:
o The first therapeutic facet joint injection is considered medically reasonable and necessary if the patient
has had two (2) medically reasonable and necessary diagnostic MBBs with each one providing a
minimum of 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
ADLs.
o Subsequent therapeutic injections at the same anatomic site are considered medically reasonable and
necessary when the patient has had at least 50% pain relief for at least three (3) months from the prior
therapeutic injection. Repeat medically reasonable and necessary therapeutic injections at the same site
of a previously treated facet joint may be done without additional diagnostic MBBs.
4. Facet Joint Denervation:
The thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median
branch) nerves will be considered to be medically reasonable and necessary as follows:
o Initial thermal RF ablation:
&#9642; After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs,
with each one providing a minimum of 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 ADLs;
OR
&#9642; After the patient has had at least one (1) medically reasonable and necessary therapeutic
injection that provided at least 50% pain relief for at least three (3) months.
o Repeat thermal facet joint RF ablation at the same anatomic site is considered medically reasonable and
necessary provided the patient had a minimum of 50% improvement in pain for at least six (6) months.
You can find this rule in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain
Management (L34892).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.