Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve two levels of the injection. We decided that the Plan does not have 
to pre-approve the third level of injection.  
 
You asked the Plan to pre-approve a three-level facet injection.. You say that the enrollee's condition would 
benefit from the requested procedure. The Plan says that the requested procedure does not meet the medical 
requirements for approval. 
 
  We decided that the Plan has to pre-approve two levels of the injection.  
 
The LCD rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 
The need for a three or four level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal. 
 
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 a three-level facet injection. Our 
reviewer says that two of the three levels of injections meet the criteria for approval. Our physician reviewer 
found this request is for a second set of medial branch blocks at three levels. The LCD limits the number of 
diagnostic block levels to two in a session. Only two levels are medically reasonable and 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 a three-level facet injection have been met. Therefore, we decided that the Plan 
has to pre-approve two levels of the injection.  
 
We also decided that the Plan does not have to pre-approve the third level of injection. 
 
The LCD rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 
The need for a three or four level procedure bilaterally may be considered under unique circumstances and with 
sufficient documentation of medical necessity on appeal.  
 
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 the third level of injection. Our 
reviewer says that the third level of injections do not meet the criteria for approval. Our physician reviewer 
found this request is for a second set of medial branch blocks at three levels. The LCD limits the number of 
diagnostic block levels to two in a session. Only two levels are medically reasonable and 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 the third level of injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the third level of injection. 
 
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.