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 the spine is the most common source of chronic pain. Chronic axial spinal pain is one of the 
major causes of disability and accounts for a substantial U.S. health burden. Chronic spine pain poses a 
peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features, and 
nonspecific radiological findings. The facet joints can cause axial spinal pain and referred pain in the 
extremities. The pathology of the pain source is due to facet joints being richly innervated by the nerve fibers 
from the medial branch of the dorsal ramus of spinal nerves. Each facet has a dual nerve supply. One exception 
is at the C2C3 zygapophysial joint, which has a singular nerve supply from the third occipital nerve (the 
superficial medial branch of C3 dorsal ramus). 
 
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 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. 
 
A. 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: 
 
        Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale; AND* 
        Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive 
conservative care management (as tolerated); AND 
        Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet 
joint synovial cyst); AND 
        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. 
    *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). 
 B. Diagnostic Facet Joint Injection Procedures (IA or MBB): 
 
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 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. 
 
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. 
 
Limitations 
        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, or with Magnetic Resonance Imaging (MRI). 
        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 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. 
        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. 
        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. 
        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. 
        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. 
        Therapeutic intraarticular facet injections are not considered medically reasonable and necessary unless 
there is documentation explaining why RFA cannot be performed. 
        Facet joint procedures in patients for the indication of generalized pain conditions (such as fibromyalgia) 
or chronic centralized pain syndromes are considered not reasonable and necessary. Individual consideration 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal.         In patients with implanted electrical devices, providers must follow manufacturer instructions and extra 
planning as indicated to ensure safety of procedure. 
 
The following are considered not medically reasonable and necessary: 
 
        Intraarticular and extraarticular facet joint prolotherapy  
        Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less 
than 80 degrees Celsius), laser neurolysis, and cryoablation 
        Intra-facet implants 
        Facet joint procedure performed after anterior lumbar interbody fusion (ALIF) 
        Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome 
        Diagnostic injections or MBB at the same level as the previously successful RFA procedure 
 
Notice: Services performed for any given diagnosis must meet all the indications and limitations stated in this 
LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all 
existing CMS national coverage determinations, and all Medicare payment rules. 
 
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.