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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 Facet Joint Interventions: 
 
    Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint 
Injections, Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration. 
 
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of 
chronic pain in patients who meet ALL of the following criteria: 
 
        1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale11; AND* 
        2. Pain that has been present for a minimum of 3 months with documented failure to respond to 
noninvasive conservative care management (as tolerated)4,12; AND 
        3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst)4,7; AND 
        4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patients pain, including but not limited to fracture, tumor, infection, or significant deformity.11 
 
    *Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the 
same pain scale for each assessment. A disability scale must also be obtained at baseline to be used for 
functional assessment (if patient qualifies for treatment). 
 
 
 
 
 Limitations 
 
   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. 
        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. 
 
You can find this information in Medicare's 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.