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 Facet joint interventions done without CT or fluoroscopic guidance are considered not 
medically reasonable and necessary. This includes facet joint interventions done without any guidance, 
performed under ultrasound guidance,4,11 or with Magnetic Resonance Imaging (MRI). General anesthesia is 
considered not medically 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 considered medically reasonable and necessary. 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. It is not expected that patients will 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. 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 
and a transforaminal epidural steroid 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. Facet joint intraarticular 
injections and medial branch blocks may involve the use of anesthetic, corticosteroids, anti-inflammatories 
and/or contrast agents and do not include injections of biologicals or other substances not FDA designated for 
this use. 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., 
MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. If there is an 
extended period of 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. Therapeutic intraarticular facet injections are not 
considered medically reasonable and necessary unless there is documentation explaining 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 medically reasonable and necessary. 
Individual consideration may be considered under unique circumstances and with sufficient documentation of 
medical necessity on appeal. In patients with implanted electrical devices, providers must follow manufacturer instructions and extra planning as indicated to ensure safety of procedure. You can find this rule in the 
Medicare Local Coverage Determination (LCD)- L34892, 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.