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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 the spine is the most common source of chronic pain. Chronic axial spinal pain is one of the 
major causes of disability and accounts for a substantial U.S. health burden. Chronic spine pain poses a 
peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features, and 
nonspecific radiological findings. 
 
The facet joints can cause axial spinal pain and referred pain in the extremities. The pathology of the pain 
source is due to facet joints being richly innervated by the nerve fibers from the medial branch of the dorsal 
ramus of spinal nerves. Each facet has a dual nerve supply. One exception is at the C2C3 zygapophysial joint, 
which has a singular nerve supply from the third occipital nerve (the superficial medial branch of C3 dorsal 
ramus). 
 
Facet joint interventions may be used in pain management for chronic cervical/thoracic and back pain arising 
from the paravertebral facet joints. The facet block procedure is an injection of a local anesthetic, with or 
without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the 
nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). Imaging guidance 
(fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. 
Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and 
reduce the likelihood of recurrence of chronic cervical/thoracic or back pain confirmed as originating in the 
facet joints medial branch nerve. 
 
There are various methods that may be used in performing facet joint denervation. Percutaneous 
radiofrequency ablation (RFA) is a minimally invasive procedure done with imaging guidance (fluoroscopy or 
CT per code descriptor) and involves using energy in the radiofrequency range to cause necrosis of specific 
nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. Conventional 
radiofrequency ablation (non-pulsed or continuous) applies thermal energy of typically 80 to 85 degrees 
Celsius. The terms RFA and radiofrequency neurotomy are used interchangeably. Both terms refer to a 
procedure that destroys the functionality of the nerve using radiofrequency energy. Non-thermal methods of 
denervation include chemical (chemodenervation), low-grade thermal energy (less than 80 degrees Celsius), 
pulsed RFA, laser neurolysis, and cryoablation. A. Facet Joint Interventions: 
Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, 
Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration. 
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: 
 
Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured 
on pain or disability scale; AND* 
Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst); AND 
There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the 
patients pain, including but not limited to fracture, tumor, infection, or significant deformity. 
*Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
B. Diagnostic Facet Joint Injection Procedures (IA or MBB): 
The primary indication of a diagnostic facet joint procedure is to diagnose whether the patient has facet 
syndrome. Intraarticular (IA) facet block(s) are considered medically reasonable and necessary as a diagnostic 
test only if MBB cannot be performed due to specific documented anatomic restrictions or there is an 
indication to proceed with therapeutic intraarticular injections. These restrictions must be clearly documented 
in the medical record and made available upon request. 
 
Diagnostic procedures should be performed with the intent that if successful, a RFA procedure would be 
considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of 
the initial diagnostic facet procedure when administered at the same level. The second diagnostic procedure 
may only be performed a minimum of 2 weeks after the initial diagnostic procedure. 
 
An initial diagnostic facet joint procedure will be considered medically reasonable and necessary when the 
patient meets the criteria outlined under the indications for facet joint interventions. 
A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet BOTH of the following criteria: 
The patient meets the criteria for the first diagnostic procedure; AND 
After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% 
relief of primary (index) pain (with the duration of relief being consistent with the agent used). 
Frequency limitation: For each covered spinal region no more than four (4) diagnostic joint sessions will be 
considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator 
cannot always be identified with the initial and confirmatory diagnostic procedure. 
 
C. Therapeutic Facet Joint Injection Procedures (IA): 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who 
meet ALL of the following criteria: 
 
The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one 
providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being 
consistent with the agent used); AND 
Subsequent therapeutic facet joint procedures at the same anatomic site result in at least consistent 50% pain 
relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using 
the same scale; AND 
Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) is in the medical record. 
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection 
(IA) sessions will be reimbursed per rolling 12 months. 
 
Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
 
You can find these rules in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L33930. 
 
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.