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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 generally consist of four types of procedures: Intraarticular (IA) 
Facet Joint Injections, Medial Branch Blocks (MBB), 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: Moderate to severe chronic neck or low back 
pain, predominantly axial, that causes functional deficit measured on pain or disability scale. Pain present for 
minimum of 3 months with documented failure to respond to noninvasive conservative management (as 
tolerated). Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst). There is no non-facet pathology per clinical assessment or radiology studies that 
could explain the source of the patient's 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: 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. 
 
B. Therapeutic Facet Joint Procedures (IA): 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL the following criteria: 
 
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 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 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: 
 
Initial thermal RFA: 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 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: 
 
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 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 
 
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). 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. 
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. 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. 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. 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. 
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. 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. 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L38803, 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.