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 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 medically reasonable and necessary 
as a diagnostic test only if a medial branch block (MBB) 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, a radiofrequency ablation procedure would 
be considered the primary treatment goal at the diagnosed level(s). A second diagnostic facet procedure is 
considered medically reasonable and 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. An initial diagnostic facet joint procedure will be considered 
medically reasonable and necessary when the patient meets the criteria outlined under the indications for facet 
joint interventions. A second confirmatory diagnostic facet joint procedure is considered medically reasonable 
and necessary in patients who meet BOTH of the following criteria: 
 
The patient meets the criteria for the first diagnostic procedure; AND 
 
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 
considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator 
cannot always be identified with the initial and confirmatory diagnostic procedure. 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL of the following criteria: 
 
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 
 
 
 Subsequent therapeutic facet joint procedures at the same anatomic site result 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 activities of daily living as compared to baseline 
measurement using the same scale; AND 
 
Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal 
pseudarthrosis, implanted electrical device) is in the medical record. For each covered spinal region no more 
than four (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months. 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.  You can 
find this rule at 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.