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). 
 
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. 
 
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. You can find this rule at the Medicare Local Coverage 
Determination (LCD) L34892: 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.