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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 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 computed tomography (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. 
 
Facet Joint Interventions generally consist of four types of procedures: Intraarticular (IA) Facet Joint Injections, 
Medial Branch Blocks (MBB), Radiofrequency Ablations (RFA) and Facet cyst rupture/aspiration. 
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). 
 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet 
ALL of 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 result 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) is in the medical record. 
Frequency limitation: For each covered spinal region no more than four (4) therapeutic facet joint injection 
(IA) sessions will be reimbursed per rolling 12 months. 
 
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.