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, Medicaid and FIDE-SNP, please refer to the Coverage Sections 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.

† Please note: this policy only applies to injections of anesthetic, corticosteroid, and/or contrast agent and does not apply to injections of biologics (e.g., platelet rich plasma, stem cells, amniotic fluid, etc.) and any other injectates.

† Facet joint injections/medial branch blocks should only be performed for neck pain or low back pain in the absence of an untreated radiculopathy (with the exception of radiculopathy caused by a facet joint synovial cyst).

† 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 that may be increased when an individual is sedated. 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.

® 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 of facet mediated pain for at least the expected minimumduration of the effect of the local anesthetic)
® A radiofrequency joint denervation/ablation procedure is being considered

® 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.

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

® Injectates other than anesthetic, corticosteroid, and/or contrast agent
® Without the use of fluoroscopic or CT guidance
® In the presence of an untreated radiculopathy (with the exception of radiculopathy caused by a facet joint synovial cyst)
® 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 (with the exception of members with clinically suspected pseudarthrosis)
® 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) contiguous spinal joint levels (with the exception of an intervening fused segment)
® Additional diagnostic facet joint injection/medial branch blocks at the same level(s) as a prior successful radiofrequency denervation/ablation procedure

® Unless performed as a second confirmatory block, all injections subsequent to the initial injection (i.e., therapeutic injections)
® When performed under ultrasound guidance

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
64490	Injection(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 agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
+64492	Injection(s), of diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
64493	Injection(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
+64494	Injection(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)
64495	Injection(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)
CPT®	Codes Considered Investigational
0213T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
0214T	Injection(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)
0215T	Injection(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)
0216T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
0217T	Injection(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)
0217T	Injection(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)
0228T	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
0231T	Injection(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 Facet Joint Interventions for Pain Management (L34892) providing coverage for Facet Joint Interventions for the diagnosis and treatment of chronic pain when all of the criteria of LCD L34892 and Local Coverage Article: Billing and Coding: Facet Joint Interventions for Pain Management (A56670) criteria are met.

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 and Local Coverage Article A56670 criteria are met.

Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L34892).

Local Coverage Article: Billing and Coding: Facet Joint Interventions for Pain Management (A56670).

LCDs 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

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

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.

___________________________________________________________________________________________________________________________

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

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30. 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.

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36. 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.

37. 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.

38. Manchikanti L, Gharibo C, Gilligan C, et al. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surgical Neurology International. 2015;6(5):S194-S235. doi:10.4103/2152-7806.156598.

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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