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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 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)
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)
You can find these rules in the Local Coverage Determination (LCD) for Facet Joint Interventions for Pain Management, L35936.
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.