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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that codes 64492 or 64495 describe a third and additional levels and should be listed separately in 
addition to the code for the primary procedure and the second level procedure and cannot be reported more 
than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in 
conjunction with 64493/64494. Codes 64492 and 64495 will only be covered upon appeal if sufficient 
documentation of medical necessity is present. You can find this information in the Centers for Medicare and 
Medicaid Services, Local Coverage Article (LCA): Billing and Coding: Facet Joint Interventions for Pain 
Management (A57826). 
 
Limitations, such as number of levels and frequency, are challenging as there is little evidence on these factors. 
Lack of consensus in the medical community about frequency of injections has been a challenge52. Societies 
have begun to offer recommendations on frequency. The NASS Coverage Recommendations recommends dual 
blocks, does not recommend therapeutic procedures, recommends limiting RFA to maximum of twice per year 
and procedures for facet joint cyst rupture to be repeated not more than once11. The 2020 Consensus 
Guidelines report recommends single diagnostic blocks, does not recommend therapeutic injections and 
recommends limiting RFA to no more than two times per year4. The Multi-MAC SME panel also provided 
input on frequency. The panel voted 1.8/5 that diagnostic injections should be a minimum of 28 days apart and 
recommended allowing sooner may be beneficial. The panel voted 3.5/5 that therapeutic injections should be a 
minimum of 3 months apart, and during treatment phase interventional procedures should be repeated only if medically necessary, and not to exceed four times per year was scored as 3.4/5. The panel voted RFA should be 
repeat only if medically necessary at minimum of 6 months apart with score of 3.9/5. The panel supported 
allowing three levels (diagnostic or therapeutic) in one session with score of 3.8/5, however prevalence data 
demonstrates that three diagnostic levels are not routine and would be under unusual circumstances. You can 
find this information in the Centers for Medicare and Medicaid Services, Local Coverage Determination 
(LCD): 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.