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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 state that Diagnostic Facet Joint 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 reasonable and necessary as a diagnostic test only if 
medial branch blocks (MMB) 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, radiofrequency ablation (RFA) 
procedure would be considered the primary treatment goal at the diagnosed level(s). 
 
A second diagnostic facet procedure is considered medically 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. Clinical circumstances that necessitate 
an exception to the 2-week duration may be considered on an individual basis and must be clearly documented 
in the medical record. 
For the first diagnostic facet joint procedure: 
 
    For the first diagnostic facet joint procedure to be considered medically reasonable and necessary, the patient 
must meet the criteria outlined under indications for facet joint interventions. 
    A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary in 
patients who meet ALL 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 
reimbursed 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 (IA or MBB): 
Therapeutic facet joint procedures is considered medically reasonable and necessary for patients who meet 
ALL 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 results 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 ADLs 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) 
 
Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (IA) 
sessions will be reimbursed per rolling 12 months. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L38841. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.