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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 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 Sections 411.15 and 
411.15(o). 
Local Coverage Determination (LCD): Facet Joint Injections, Medial Branch Blocks, and Facet Joint 
Radiofrequency Neurotomy (L35996) -  General Procedure Requirements: 
  Pre-procedural documentation must include a complete initial evaluation including history and an 
appropriately focused musculoskeletal and neurological physical examination. There should be a 
summary of pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.  
  A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. 
Required elements of the note include a description of the techniques employed, nerves injected and 
sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-
procedural pain assessments. With RF neurotomy, electrode position, cannula size, lesion parameters, 
and electrical stimulation parameters and findings must be specified and documented.  
  Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or 
computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance 
will not be reimbursed.  
  A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images 
which adequately document the needle position and contrast medium flow (excluding RF ablations and 
those cases in which using contrast is contraindicated, such as patients with documented contrast 
allergies), must be retained and submitted if requested.  
   In order to maintain target specificity, total IA injection volume must not exceed 1.0 ml per cervical 
joint or 2 ml per lumbar joint, including contrast. Larger volumes may be used only when performing a 
purposeful facet cyst rupture in the lumbar spine.  
  Total MBB anesthetic volume shall be limited to a maximum of 0.5 ml per MB nerve for diagnostic 
purposes and 2 ml for therapeutic. For a third occipital nerve block, up to 1.0 ml is allowed for 
diagnostic and 2 ml for therapeutic purposes.  
  In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or 
dexamethasone or equivalents shall be injected during any single injection session.  
  Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) 
may be acceptably performed without steroids. 
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.