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: 
1. 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
 
2. 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
 
3. 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. 
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 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 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. 
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., MBB, IA, facet cyst ruptures, and RFA 
ablations) that are performed during the same day. 
7. 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. 
8. 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
 
9. 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
 
10. 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 Centers for Medicare and Medicaid Services, 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.