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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 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. 
 
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. 
 
Throughout this document, societal recommendations with the grading of evidence are referenced. There are 
multiple systems to grade or rank the quality of medical evidence and develop evidence-based 
recommendations. Not all grading systems are equivalent, so while there are typically similarities in the grades or recommendations from various grading systems, they must be considered independent of the other. The 
references in this document refer to the following grading systems. 
 
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.