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 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 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). 
 
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: 
  
       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.