Appeal type: unknown
Decision: unknown

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 Covered Indications 
 
1. Facet Joint Interventions: 
 
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 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. 
 
    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 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:   
 
    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. 
    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: 
 
    Initial thermal RF ablation: 
        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 
        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. 
    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.  
 
Limitations 
 
The following are considered not reasonable and necessary and therefore will be denied: 
 
   1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and 
necessary. This includes facet joint interventions done without any guidance, performed under ultrasound 
guidance, or with Magnetic Resonance Imaging (MRI). Please refer to LCD L35094 Services That Are Not 
Reasonable and Necessary, for information on paravertebral facet injections with ultrasound guidance. 
    2. Intraarticular and extraarticular facet joint prolotherapy are considered not reasonable and necessary. 
    3. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less 
than 80 degrees Celsius), pulsed, laser, and cryoablation are considered not reasonable and necessary. 
    4. General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither 
conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint 
injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given 
on redetermination (appeal) for payment in rare unique circumstances if the medical necessity of sedation is 
unequivocal and clearly documented in the medical record. Please refer to LCD L35049 Monitored Anesthesia 
Care for additional information. Frequent reporting of these services together may trigger focused medical 
reviews. 
    5. It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar spinal 
regions. Therefore, the routine performance of facet joint interventions (both diagnostic and therapeutic) to 
both spinal regions may trigger focused medical review. 
   6. It is not routinely necessary for multiple blocks (e.g., epidural block, sympathetic block) to be provided to 
 
 
a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or 
lack of diagnosis. If performed, the medical necessity of each injection (at the same or at different level[s]) 
must be clearly documented in the medical record. For example, performance of both paravertebral facet joint 
injection(s) and a transforaminal epidural injection (EI) at the same spinal level at the same encounter would 
not be expected unless a synovial cyst is compressing the nerve root. In this situation, EI may provide relief for 
the radicular pain while the facet cyst rupture allows nerve root decompression. For additional information on 
epidural injections, please refer to LCD L36920 Epidural Injections for Pain Management. Frequent reporting 
of multiple blocks on the same day may trigger focused medical review. 
 
You can find this information in Medicare's 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.