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 Coverage Indications, Limitations, and/or Medical Necessity  
A. Covered Indications Facet Joint Interventions: 
Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, 
Medial Branch Blocks (MBB), and 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 the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated)  
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. 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 at baseline, after each diagnostic procedure using the same pain or 
disability scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment).  
 
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: 
 
 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.  A second confirmatory 
diagnostic facet joint procedure is considered medically reasonable and necessary in patients who meet ALL 
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 
reimbursed per rolling 12 months, in recognition that the pain generator cannot always be identified with the 
initial and confirmatory diagnostic procedure. You can find this rule at Centers for Medicare and Medicaid 
Services, Local Coverage Determination (LCD) L38765, 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.