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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 limitations for facet joint interventions: 
 
        Facet joint interventions done without CT or fluoroscopic guidance are considered not medically 
reasonable and necessary. This includes facet joint interventions done without any guidance, performed under 
ultrasound guidance,4,11 or with Magnetic Resonance Imaging (MRI).4 
        General anesthesia is considered not medically 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 considered medically reasonable and necessary. 
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.4 
        It is not expected that patients will 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 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. 
        Facet joint intraarticular injections and medial branch blocks may involve the use of anesthetic, 
corticosteroids, anti-inflammatories and/or contrast agents and do 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., 
MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. 
        If there is an extended period of 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 considered medically reasonable and necessary unless there is documentation explaining why RFA cannot be performed.5,42,43,44 
        Facet joint procedures in patients for the indication of generalized pain conditions (such as fibromyalgia) 
or chronic centralized pain syndromes are considered not medically reasonable and necessary. Individual 
consideration may be considered under unique circumstances and with sufficient documentation of medical 
necessity on appeal.56 
        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 information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L34892. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.