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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 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 two-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:  
 
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. 
 
        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)      Therapeutic Facet Joint Procedures (IA): 
 
    Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL of the following criteria: 
 
    Frequency Limitations: For each covered spinal region no more than four (4) therapeutic facet joint (IA) 
sessions will be reimbursed per rolling 12 months. 
            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) 
 
    Facet Joint Denervation: 
 
    The thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (median 
branch) nerves are considered medically reasonable and necessary for patients who meet ALL the following 
criteria: 
 
    Frequency Limitation: For each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months. 
             Initial thermal RFA: 
                 After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of 
relief being consistent with the agent used) AND 
                Repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and 
necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) 
months 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; 
 
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 blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations) that are 
performed during the same day. 
 
You can find this information in the Local Coverage Determination (LCD) Facet Joint Interventions for Pain 
Management L38765. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.