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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 say that facet joint interventions may be used in pain management for chronic cervical/thoracic and 
back pain arising from the paravertebral facet joints. The facet block procedure is an injection of a local 
anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint 
space around the nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). 
Imaging guidance (fluoroscopy or computed tomography (CT) per code descriptor) is used to assure accurate 
placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used 
to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or 
back pain confirmed as originating in the facet joints medial branch nerve. 
 
There are various methods that may be used in performing facet joint denervation. Percutaneous 
radiofrequency ablation (RFA) is a minimally invasive procedure done with imaging guidance (fluoroscopy or 
CT per code descriptor) and involves using energy in the radiofrequency range to cause necrosis of specific 
nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. Conventional 
radiofrequency ablation (non-pulsed or continuous) applies thermal energy of typically 80 to 85 degrees 
Celsius. The terms RFA and radiofrequency neurotomy are used interchangeably. Both terms refer to a 
procedure that destroys the functionality of the nerve using radiofrequency energy. Non-thermal methods of 
denervation include chemical (chemodenervation), low-grade thermal energy (less than 80 degrees Celsius), 
pulsed RFA, laser neurolysis, and cryoablation. 
 
Facet Joint Denervation: 
An initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is 
considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable 
and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain (with the duration of relief being consistent with the agent used). 
 
Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary 
provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at 
least 50% consistent improvement in the ability to perform previously painful movements and activities of 
daily living (ADLs) as compared to baseline measurement using the same scale. Frequency limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
 
You can find these rules 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.