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 Facet Joint Interventions are considered medically reasonable and necessary for the 
diagnosis and treatment of chronic pain in patients who meet ALL the following criteria: 
1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit 
measured on pain or disability scale* 
2. Pain present for minimum of 3 months with documented failure to respond to noninvasive conservative 
management (as tolerated) 
3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by 
facet joint synovial cyst) 
4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the 
source of the patient's pain, including but not limited to fracture, tumor, infection, or significant 
deformity. 
Limitations 
1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and 
necessary. This includes facet joint interventions done without any guidance, performed under 
ultrasound guidance, or with magnetic resonance imaging (MRI). 
2. General anesthesia is considered not 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 reimbursable. 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. 3. It is not expected that patients will routinely 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(s) and a transforaminal 
epidural 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. 
5. Facet joint intraarticular injections and medial branch blocks may involve the use of anesthetic, 
corticosteroids, anti-inflammatories and/or contrast agents, and does not include injections of 
biologicals or other substances not FDA designated for this use. 
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., medial branch block (MBB), intraarticular injections (IA), facet cyst 
ruptures, and RFA ablations that are performed during the same day. 
7. If there is an extended 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. 
8. Therapeutic intraarticular facet injections are not covered unless there is justification in the medical 
documentation on 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. 
9. In patients with implanted electrical devices, providers must follow manufacturer instructions and extra 
planning as indicated to ensure safety of procedure. 

You can find this rule at the Medicare Local Coverage Determination (LCD) L35936: Facet Joint Interventions 
for Pain Management. 
 
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.