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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 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.  
 
Leggett et al. (2014) conducted a systematic review to determine the efficacy of RFA for chronic low back pain 
associated with lumbar facet joints, sacroiliac joints, discogenic low back pain, and the coccyx. Included 
articles were sham-controlled randomized controlled trials (RCTs), assessed the efficacy of RFA, reported at 
least one month of follow-up, and included participants who had experienced back pain for at least three 
months. Eleven sham controlled RCTs were included: three studies involving discogenic back pain, six studies 
involving lumbar facet joint pain, and two studies involving sacroiliac joint pain. No studies were identified 
assessing the coccyx. The evidence supports RFA as an efficacious treatment for lumbar facet joint and 
sacroiliac joint pain, with five of six and both of the RCTs demonstrating statistically significant pain 
reductions, respectively. The evidence supporting the RFA for the treatment of discogenic pain is mixed. 
Future studies should examine the clinical significance of the achieved pain reduction and the long-term 
efficacy of RFA. 
 
Agency for Healthcare Research and Quality (AHRQ) Technology Assessment Program: Pain Management 
Injection Therapies for Low Back Pain (2015) authors used predefined criteria and selected randomized trials 
of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical 
back pain that compared effectiveness or harms of the epidural, facet joint, or sacroiliac corticosteroid 
injections versus placebo or other interventions. Also included were randomized trials that compared different injection techniques and large (sample sizes greater than 1000) observational studies of back injections that 
reported harms. Seventy-eight randomized trials of epidural injections, 13 trials of facet joint injections, and 
one trial of sacroiliac injections were included. Limited evidence suggested that epidural corticosteroid 
injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid 
injections are not effective for presumed facet joint pain. 
 
Limitations:  
 
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. 
 
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. You can find this information in Medicare's Local Coverage Determination 
(LCD): Facet Joint Interventions for Pain Management (L38773). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.