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 say the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint 
(medial branch (MB)) nerves are considered medically reasonable and necessary for patients who 
meet ALL the following criteria: 
 
Frequency Limitation: For each covered spinal region no more than 2 radiofrequency sessions will be 
reimbursed per rolling 12 months. 
1.  
a.  Initial thermal RFA: 
i.  After the patient has had at least 2 medically reasonable and necessary diagnostic 
medial branch blocks (MBBs), with each 1 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 6 months or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living (ADLs) as 
compared to baseline measurement using the same scale 

Limitations 
1. Facet joint interventions done without computed tomography (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 intra-articular (IA) 
facet joint injections or MBBs 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 1 
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 at different level[s]) must be clearly documented in the medical record. 
For example, the performance of both paravertebral facet joint procedure(s) 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. 
5. Facet joint IA injections and MBBs may involve the use of anesthetic, corticosteroids, anti-
inflammatories and/or contrast agents, and does not include injections of biologicals or other substances 
not United States Food and Drug Administration (FDA) designated for this use. 
6. One to 2 levels, either unilateral or bilateral, are allowed per session per spine region. The need for a 3 
or 4-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., MBBs, IA injections, facet cyst ruptures, and RFAs) that are performed during the same day. 
7. If there is an extended time, 2 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 IA facet injections are not covered unless there is 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. IA and extra-articular 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 (ALIF). 
5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint 
syndrome 
6. Diagnostic injections or MBB at the same level as the previously successful RFA procedure 
 
You can find this information in the Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management (L38765). 
 
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.