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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 computed tomography (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. 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). You can find these rules in 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.