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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Treatment
Policy Number:157
Effective Date: 10/22/2018
Original Policy Date:07/12/2016
Last Review Date:06/11/2019
Date Published to Web: 03/12/2018
Subject:
Facet Joint Injections/Medial Branch Blocks

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

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CMM-201Facet Joint Injections/Medial Branch Blocks
201.1Definitions
201.2General Guidelines
201.3Indications
201.4Non-Indications
201.5Procedure (CPT) Codes
201.6References

CMM-201.1 Definitions

Facet Joint Injections/medial branch blocks refer to the injection of local anesthetic and possibly a corticosteroid in the facet joint capsule or along the nerves supplying the facet jointsfrom C2-3 to L5-S1. The injection/block applies directly to the facet joint(s) blocked and not to the number of nerves blocked that innervate the facet joint(s). Even though either procedure can be used to diagnose facet joint pain, a medial branch block is generally considered more appropriate. A diagnostic facet joint injection/medial branch block is considered positive when there is at least 80% pain relief for the duration of the effect of the local anesthetic used.


Policy:
(NOTE: For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

CMM-201.2 General Guidelines

The determination of medical necessity for the performance of facet joint injections/medial branch blocks is always made on a case-by-case basis.

Facet joint injections/medial branch blocks should only be performed for neck pain or low back pain in the absence of an untreated radiculopathy.

A diagnostic facet joint injection/medial branch block may be performed to determine whether spinal pain orginates in the facet joint or nerves innervating the facet joint. A second facet joint injection/medial branch block must be performed to confirm the validity of the clinical response of the initial injection and should only be performed with the intent that if successful, a radiofrequency joint denervation/ablation procedure (facet neurotomy, facet rhizotomy) would be considered as an option at the diagnosed level(s).

More than two facet injections/medial branch blocks at the same level are considered to be therapeutic rather than diagnostic. Following a spinal fusion, a diagnostic facet joint injection/medial branch block may be performed immediately above or below the fused level if a prior injection/block was negative. There is a paucity of published scientific evidence supporting the use of therapeutic facet joint injections/medial branch blocks. Although limited, some anecdotal evidence supports a facet joint injection/medial branch block as an alternative treatment to a radiofrequency ablation/neurotomy for a subset of individuals when the initial facet joint injection/medial branch blocks has resulted in significant pain relief (i.e., > 50%) for at least 12 weeks following the facet joint injection/medial branch block and the individual is not a candidate for a radiofrequency joint denervation/ablation procedure. For this specific subset of individuals a repeat facet joint injection may be considered appropriate, although no sooner than six months from when the prior diagnostic injection was performed.

It may be necessary to perform the facet joint injection/medial branch block at the same facet joint level(s) bilaterally, however, no more than three (3) facet joint levels should be injected during the same session/procedure.

Facet joint injections/medial branch blocks are not without risk and can expose individuals to potential complications. As a result, when performing facet joint injections/medial branch blocks, the use of supplemental sedation in addition to local anesthesia is not required and not recommended.

CMM-201.3 Indications

An initial diagnostic facet joint injection/medial branch block is considered medically necessary to determine whether chronic neck or back pain is of facet joint origin when ALL of the following criteria are met:

    Pain is exacerbated by facet loading maneuvers on physical examination
    Pain has persisted despite at least four weeks of appropriate conservative treatment (e.g., physical methods including physical therapy, chiropractic care and exercise, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or analgesics) unless contraindicated and the reason(s) for contraindication(s) is/are documented in the medical record
    Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculpathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation).
    The spinal motion segment is not posteriorly fused.

A second diagnostic facet joint injection/medial branch block, performed to confirm the validity of the clinical response to the initial facet joint injection, is considered medically necessary when ALL of the following criteria are met:
    Administered at the same level as the initial block
    The initial diagnostic facet joint injection produced a positive response (i.e., at least 80% pain relief for the duration of the effect of the local anesthetic)
    A radiofrequency joint denervation/ablation procedure is being considered

An intra-articular facet joint injection performed with synovial cyst aspiration, in addition to a transforaminal epidural steroid injection, is considered medically necessary when the following criteria are met:
    Advanced diagnostic imaging studies (e.g., MRI, CT, CT myelogram) confirm compression or displacement of the corresponding nerve root by a facet joint synovial cyst
    Clinical correlation with the individual’s signs and symptoms of radicular pain or radiculopathy, based on history and physical examination.

CMM-201.4: Non-Indications

Performance of a facet joint injection/medial branch block is considered not medically necessary when performed for ANY of the following indications:

    Without the use of fluoroscopic or CT guidance
    In the presence of an untreated radiculopathy
    When a radiofrequency joint denervation/ablation procedure (i.e., facet neurotomy, facet rhizotomy) is not being considered
    The facet joint injection is performed at a fused posterior spinal motion segment
    On the same day of service when performing other injections (e.g., epidural steroid, sacroiliac) in the same region
    Performance of injections/blocks on more than three (3) joint levels
    Additional diagnostic facet joint injection/medial branch blocks at the same level(s) as a prior successful radiofrequency denervation/ablation procedure

Performance of a facet joint injection/medial branch block is considered investigational when performed for ANY of the following indications:
    Unless performed as a second confirmatory block, all injections subsequent to the initial injection (i.e., therapeutic injections)
    When performed under ultrasound guidance

CMM-201.5 Procedure (CPT) Codes

This guideline relates to the CPT code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required.
CPT
Code Description/Definition
64490Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level

+64491
Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), second level (List separately)

+64492
Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), third and any additional level(s) (List separately)
64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level
+64494Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, second level (List separately)
64495Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, third and any additional level(s) (List separately)
0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
0214TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)
0215TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
0217TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)
0218TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
CPT
Codes Considered Investigational
0228TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
0231TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)
This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the health plan and is based on the individual’s policy or benefit entitlement structure as well as claims processing rules.


Medicare Coverage:
There is no National Coverage Determination (NCD) Facet Joint Injections/Medial Branch Blocks. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued (2) Local Coverage Determinations related to this service: Facet Joint Interventions for Pain Management (L34892) and Local Coverage Determination (LCD):
Paravertebral Facet and Sacroiliac Joint Injections (L34892). On 8/17/18, Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, placed Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892) on hold. Therefore, coverage decisions are to be made based on Local Coverage Determination (LCD): Paravertebral Facet and Sacroiliac Joint Injections (L34892) until Novitas re-activates LCD: Facet Joint Interventions for Pain Management (L34892).

On 11/27/18, Novitas announced its intention to reactivate (L34892) Facet Joint Interventions for Pain Management with an effective date of 1/03/19. Therefore, Facet Joint Injections/Medial Branch Blocks performed on or after 01/03/2019 will be covered based on Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management (L34892). For services performed prior to 01/03/2019, coverage is based on Local Coverage Determination (LCD): Paravertebral Facet and Sacroiliac Joint Injections (L34892) criteria.

Eligibility and coverage for Medicare Advantage Products differs from the Horizon policy. Services represented by CPT codes 64495 and 27096, and HCPCS code G0260 are covered for Medicare Advantage Products when the LCD L34892 criteria is met. CPT codes 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T and 0231Tare noncovered for Medicare Advantage Products per Local Coverage Determination (LCD): Services That Are Not Reasonable and Necessary (L35094). Please refer to the below Novitas Solutions Inc, LCDs for eligibility and coverage.

Local Coverage Determination (LCD): Paravertebral Facet and Sacroiliac Joint Injections (L34892).
Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892). (Effective 1/03/19).
Local Coverage Determination (LCD): Services That Are Not Reasonable and Necessary (L35094).

Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/page/pagebyid?contentId=00024370&_afrLoop=421114819512400#!%40%40%3F_afrLoop%3D421114819512400%26contentId%3D00024370%26_adf.ctrl-state%3D7y3awk7jy_17
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Facet Joint Injections/Medial Branch Blocks
Cervical or Thoracic Facet Joint Injections / Medial Branch Blocks
Medial Branch Blocks, Cervical or Thoracic
Facet Injection
Facet Block
Lumbar Facet Joint Injections / Medial Branch Blocks
Cervical Facet Joint Injections / Medial Branch Blocks

References:
1. Airaksinen O, Brox J, Cedraschi C, et al. On behalf of the COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(Supplement 2):s192-s300.

2. Allen TL, Tatli Y, Lutz, GE. Fluoroscopic percutaneous lumbar zygoapophyseal joint cysts rupture: a clinical outcome study. Spine. 2009 May;9(5): 387-95.

3. American Medical Association. Current Procedural Terminology: CPT 2008, Professional Edition. AMA Press, 2007.

4. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guideline, 2nd Ed. 2008.

5. Bogduk N. A narrative review of intra-articular corticosteroid injections for low back pain. Pain Med. 2005;6(4):287-296.

6. Boswell M, Colson J, Sehgal N, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229-253.

7. Boswell M, Colson J, Spillane W. Therapeutic Facet Joint Interventions in Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications. Pain Physician. 2005;8:101-114.

8. Boswell MV, Manchikanti L, Kaye AD, et al. A best-evidence systematic appraisal of the


    diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain.

    Pain Physician 2015;18:E497-E533.


9. Boswell M, Shah R, Everett C, et al. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician. 2005;8(1):1-47.

10. Boswell M, Trescot A, Datta S, et al. American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10(1):7-111.

11. Civelek E, Cansever T, Kabatas S, et al. Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain. Turk Neurosurg. 2012;22:200-206.

12. Cohen S, Raja S. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007;106:591-614.

13. Dreyfuss P, Dreyer S. NASS. Lumbar zygapophysial (facet) joint injections. Spine J. 2003;3(3 Suppl):50S-59S.

14. Dreyfus P, Kaplan M, Dreyer S, ed Lennard T. Zygopophyseal Joint Injection Techniques in the Spinal Axis. Procedures in Clinical Practice. Second Edition. Hanley and Belfus Inc. Philidelphia. 2000, page 276.

15. Friedly J, Chan L, Deyo R. Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine. 2007;32(16):1754-1760.

16. Friedrich K, Nemec S, Peloschek P, et al. The prevalence of lumbar facet joint edema in patients with low back pain. Skeletal Radiol. 2007;36(8):755-760.

17. Fritz J, Niemeyer T, Clasen S, et al. Management of chronic low back pain: rationales, principles, and targets of imaging-guided spinal injections. Radiographics.2007;27(6):1751-1771.

18. Fuchs S, Erbe T, Fischer H, Tibesku C. Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine. J Vasc Interv Radiol. 2005;16:1493-1498.

19. Fuchs S, Erbe T, Fischer HL, Tibesku CO. Intraarticular hyaluronic acid versus glucocorticoidinjections for nonradicular pain in the lumbar spine. J Vasc Interv Radiol. 2005; 16:1493-1498.

20. Hancock M, Maher C, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007;16(10):1539-1550.

21. IPM Guidelines. An Update of Comprehensive Evidenced - Based Guidelines For Interventional Techniques in Chronic Spinal Pain. Part 2: Guidance and Recommendations. Pain Physician 2013: 16;S49 – S283.

22. Kirpalani D, Mitra R. Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil. 2008;89(4):770-774.

23. Lakemeier S, LInd M, Schultz W, Fuchs-Winkelmann S, Timmesfeld N, Foelsch C, Peterlein CD. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: A randomized, controlled, double-blind trial. Anesth Analg. 2013;117:228-235.

24. Laslett M, McDonald B, Aprill C, et al. Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Spine J. 2006;6(4):370-379.

25. Laslett M, Oberg B, April C, McDonald B. Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test. BMC Musculoskelet Disord. 2004;16:5:43.

26. Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery. 1995;36:732–9.

27. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician. 2013;16:S49-S283.

28. Manchikanti L, Cash K, Pampati V, Fellows B. Influence of psychological variables on the diagnosis of facet joint involvement in chronic spinal pain. Pain Physician. 2008;11(2):145-160.

29. Manchikanti L, Damron K, Cash K, et al. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial. Pain Physician.2006;9(4):333-346.

30. Manchikanti L, Kaye AD, Boswell MV, et al. A systematic review and best evidence synthesis of the effectiveness of therapeutic facet joint interventions in managing chronic spinal pain. Pain Physician. 2015; 18:E535-E582.

31. Manchikanti L, Manchikanti K, Cash K, et al. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician. 2008;11(1):67-75.

32. Manchikanti L, Manchikanti K, Manchukonda R, et al. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial. Pain Physician. 2007;10(3):425-40.

33. Manchikanti L, Manchukonda R, Pampati V, et al. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007;88(4):449-55.

34. Manchikanti L, Singh V, Falco F, et al. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial. Pain Physician. 2008;11(2):121-132.

35. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: A randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010;7:124-135.

36. Manchikanti L, Singh V, Falco FJE, Cash KA, Fellows B. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: A randomized, double-blind controlled trial. Pain Physician. 2010;13:437-450.

37. Manchikanti L, Pampati V, Bakhit C, et al. Effectiveness of lumbar facet joint nerve blocks in chronic low back pain: A randomized clinical trial. Pain Physician. 2001;4:101-117.

38. Manchikanti L, Singh V, Falco FJE, Cash KA, Pampati V, Fellows B. The role of thoracic medial branch locks in managing chronic mid and upper back pain: A randomized, double-blind, active control trial with a 2-year follow-up. Anesthesiol Res Pract. 2012;2012:585806.

39. Manchukonda R, Manchikanti K, Cash K, et al. Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech. 2007;20(7):539-545.

40. Nordin M, Carragee E, Hurwitz L, et al; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;15;33(4 Suppl):S153-S169.

41. North American Spine Society (NASS). NASS Coverage Policy Recommendation. Facet Joint Intervention. Copyright 2016 North American Spine Society.

42. Park KD, Jee H, Nam HS, Cho SK, Kim HS, Park Y, Lim OK. Effect of medial branch block in chronic facet joint pain for osteoporotic compression fracture: one year retrospective study. Ann Rehabil Med. 2013 Apr;37(2):191-201. doi: 10.5535/arm.2013.37.2.191. Epub 2013 Apr30.

43. Park SC, Kim KH. Effect of adding cervical facet joint injections in a multimodal treatment program for long-standing cervical myofascial pain syndrome with referral pain patterns of cervical facet joint syndrome. J Anesth. 2012;26:738-745.

44. Patel J, Schneider B, Smith C on behalf of SIS Patient Safety Committee. Intrarticular Corticosteroid Injections and hyperglycemia. 10/4/17.

45. Resnick D, Choudhri T, Dailey A, et al. American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine. 2005;2(6):707-715.

46. Ribeiro LH, Furtado RN, Konai MS, et al. Effect of facet joint injection versus systemic steroids in low back pain: A randomized controlled trial. Spine (Phila Pa 1976). 2013;38:1995-2002.

47. Schneider G, Jull G, Smith A, Emery C, Faris P, Cook C, Frizzell B, Salo P. Derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. Arch Phys Med Rehabil, 2014; 95(9): 1695-701.

48. Sehgal N, Dunbar E, Shah R, Colson J. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician. 2007;10(1):213-228.

49. van Tulder M, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J. 2006; Suppl 1:S82-92.

50. Workloss Data Institute. Official Disability Guidelines. 2015.

51. Yun DH, Kim HS, Yoo SD, Kim DH, Chon JM, Choi SH, Hwang DG, Jung PK. Efficacy of ultrasonography-guided injections in patients with facet syndrome of the low lumbar spine. Ann Rehabil Med. 2012;36:66-71.

52. Shah RD, Cappiello D, Suresh S. Interventional procedures for chronic pain in children and adolescents: a review of the current evidence. World Institute of Pain. 2016: 359-369.



Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

    64490
    64491
    64492
    64493
    64494
    64495
    0213T
    0214T
    0215T
    0216T
    0217T
    0218T
    0228T
    0231T
HCPCS

* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy

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