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If the initial injection did not produce a positive response, a second diagnostic injection is considered not medically necessary.Īdditional sets of facet injections or medial branch blocks at the same levels and side are considered experimental and investigational because they have no proven value.Īetna considers diagnostic facet joint injections not medically necessary where radiofrequency facet neurolysis is not being considered.ĭiagnostic facet joint injections are considered experimental and investigational for neck and back pain with untreated radiculopathy.įacet joint injections are considered experimental and investigational as therapy for back and neck pain and for all other indications because their effectiveness for these indications has not been established.

A second diagnostic facet injection (intraarticular and medial branch block) is considered medically necessary to confirm the validity of the clinical response to the initial facet injection when it is administered at the same level as the initial facet injection, and where the initial facet injection produced a positive response (i.e., resulted in an 80% relief of facet mediated pain for at least the expected minimum duration of the effect of the local anesthetic).

These may be performed bilaterally during the same session for a total of up to six injections.

Injection of no more than three (3) facet joint levels are considered medically necessary during the same session/procedure.

Radiofrequency facet neurolysis is being considered.

Pain has persisted despite six or more weeks of conservative treatment (including, systemic medications, and/or physical therapy) and.

Pain has lasted more than 3 months and.

Imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion) and.

Facet mediated pain is confirmed by provocative testing on physical examination (to confirm that pain is exacerbated by extension and rotation) and.Member has symptoms suggestive of facet joint syndrome (symptoms of facet joint syndrome include absence of radiculopathy, pain that is aggravated by extension, rotation or lateral bending of the spine and is not typically associated with any neurological deficits) and.

This Clinical Policy Bulletin addresses invasive procedures for back pain.Īetna considers any of the following injections or procedure medically necessary for the treatment of back pain provided that only one invasive modality or procedure will be considered medically necessary at a time.Īn initial facet injection (intra-articular and medial branch block) from C2-3 to L5-S1 is considered medically necessary for the diagnosis of facet pain in persons with severe chronic neck and back pain when the following criteria are met: Number: 0016 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References