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 state that: 
 
A. Diagnostic Facet Joint 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 reasonable and necessary as a diagnostic test only if 
medial branch blocks (MMB) 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, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
A second diagnostic facet procedure is considered medically 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. Clinical circumstances that necessitate 
an exception to the two-week duration may be considered on an individual basis and must be clearly 
documented in the medical record. 
For the first diagnostic facet joint procedure: 
a. For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the 
patient must meet the criteria outlined under indications for facet joint interventions. 
b. A second confirmatory diagnostic facet joint procedure is considered medically reasonable and 
necessary in patients who meet ALL the following criteria: 
1.  
i. The patient meets the criteria for the first diagnostic procedure; AND ii. 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 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure.  
B. Therapeutic Facet Joint Procedures (IA): 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who 
meet ALL the following criteria: 
a. 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 
b. Subsequent therapeutic facet joint procedures at the same anatomic site results 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 
c. Documentation of why the patient is not a candidate for radiofrequency ablation (such as established 
spinal pseudarthrosis, implanted electrical device) 
Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (IA) 
sessions will be reimbursed per rolling 12 months. 
C. Facet Joint Denervation: 
The thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) 
nerves are considered medically reasonable and necessary for patients who meet ALL the following criteria: 
1.  
a. Initial thermal RFA: 
i. After the patient has had at least two (2) medically reasonable and necessary diagnostic 
MBBs, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent 
used) AND 
ii. Repeat thermal facet joint RFA at the same anatomic site is considered medically 
reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months 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; 
Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
D. Facet Cyst Aspiration/Rupture 
Intra-articular facet joint injection performed with synovial cyst aspiration is considered medically necessary 
when both of the following criteria are met: 1. Advanced diagnostic imaging study (e.g., MRI/CT/myelogram) confirm compression or displacement 
of the corresponding nerve root by a facet joint synovial cyst; AND 
2. Clinical and physical symptoms related to synovial facet cyst are documented 
Frequency Limitation: Cyst aspiration/rupture may be repeated once and only if there is 50% or more consistent 
improvement in pain for at least three (3) months. 
Limitations 
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). 
2. 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. Frequent reporting 
of these services together may trigger focused medical review. 
3. It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar 
spinal regions. Therefore, facet joint interventions (both diagnostic and therapeutic) are limited to one 
spinal region per session. 
4. It is not routinely necessary for multiple blocks (e.g., epidural injections, sympathetic blocks, trigger 
point injections, etc.) to be provided to a patient on the same day as facet joint procedures. 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 a different level[s]) must be clearly documented in the medical record. 
For example, the performance of both paravertebral facet joint procedures(s) and a transforaminal 
epidural injection (TFESI) at the same or close spinal level at the same encounter would not be 
expected unless a synovial cyst is compressing the nerve root. In this situation, TFESI may provide 
relief for the radicular pain, while the facet cyst rupture allows nerve root decompression. Frequent 
reporting of multiple blocks on the same day may trigger a focused medical review. 
5. Facet joint intraarticular injections and medial branch blocks may involve the use of anesthetic, 
corticosteroids, anti-inflammatories and/or contrast agents, and does not include injections of 
biologicals or other substances not FDA designated for this use. 
6. 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. A session is a time period, which includes all 
procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA 
ablations that are performed during the same day. 
7. If there is an extended time, two years or more, since the last RFA and/or there is a question as to the 
source of the recurrent pain then diagnostic procedures must be repeated. 
8. Therapeutic intraarticular facet injections are not covered unless there is justification in the medical 
documentation on why RFA cannot be performed. Facet joint procedures in patients for the indication 
of generalized pain conditions (such as fibromyalgia) or chronic centralized pain syndromes are 
considered not reasonable and necessary. Individual consideration may be considered under unique 
circumstances and with sufficient documentation of medical necessity on appeal. 
9. In patients with implanted electrical devices, providers must follow manufacturer instructions and extra 
planning as indicated to ensure safety of procedure. 
The following are considered not reasonable and necessary and therefore will be denied: 
1. Intraarticular and extraarticular facet joint prolotherapy 2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less 
than 80 degrees Celsius), laser neurolysis, and cryoablation. 
3. Intra-facet implants 
4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF. 
5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint 
syndrome 
6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure 
You can find this rule at the Medicare Local Coverage Determination (LCD) L35936: Facet Joint Interventions 
for Pain Management. 
 
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.