GENERAL INFORMATION 
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Special Note

• Any injection performed at least two years from prior injections in the same region will be considered a new episode of care and the INITIAL injection requirements must be met for approval. Events such as surgery on the same spinal region or any new pathology would also prompt a new episode of care.
• Unilateral injections performed at the same level on the right vs. left within 1 month of each other would be considered as one procedure toward the total number of facet procedures allowed per 12 months

Policy 

INDICATIONS FOR FACET JOINT INJECTIONS OR MEDIAL BRANCH NERVE BLOCKS
Facet Joint Pain ¹
To confirm non-radicular pain suggestive of facet joint or pars interarticularis origin, ALL the following must be met:

• History of mainly axial pain or non-radicular pain unless stenosis is caused by synovial cyst (2)
• Lack of evidence that the primary source of pain being treated is from sacroiliac joint pain, discogenic pain, disc herniation, or radiculitis
• Chronic lumbar spondylolysis 
  • Imaging studies confirming the presence of a pars interarticularis fracture/defect are required
• Pain causing functional disability or average pain level of ≥ 6 (scale of 0 to 10) related to the requested spinal region (3)
• Duration of pain for at least 3 months
• Failure to respond to non-operative conservative treatment* targeting the requested spinal region for a minimum of six (6) weeks in the last six (6) months unless the medical reason this treatment cannot be done is clearly documented 
  • OR details of engagement in ongoing non-operative conservative treatment* if the individual has had prior spinal injections in the same region

Note: Failure of conservative treatment is defined as one of the following:

• Lack of meaningful improvement after a full course of treatment; OR
• Progression or worsening of symptoms during treatment; OR
• Documentation of a medical reason the member is unable to participate in the treatment (Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute ‘inability to complete’ treatment)

Imaging Guidance^4,5,6

• The facet joint is commonly identified under image guidance by Computed tomography (CT) or Fluoroscopy. Medial Branch Blocks are commonly identified by Fluoroscopy. With proper use by skilled interventional pain physicians with ultrasound experience, the use of ultrasound guidance is similar to CT or Fluoroscopy but can have a lower accuracy of needle placement. 
• Ultrasound guidance can be an effective alternative if CT or fluoroscopy guided techniques are contraindicated; however, individual patient factors such as poor visualization due to deeper tissue layers e.g., increased Body Mass Index (BMI) may contribute to substandard image resolution..

NOTE: ALL procedures must be performed under imaging guidance

Repeat Injections ^1,7
Facet joint injections and medial branch nerve blocks may be repeated only as MEDICALLY NECESSARY. Each injection requires an authorization, and the following criteria must be met for repeat injections: 

Initial Treatment Phase

• Up to 2 diagnostic injections may be performed in the initial diagnostic phase, no sooner than 2 weeks apart, provided at least 50% pain relief or significant documented functional improvement is obtained 
• If the most recent injection was a diagnostic block with local anesthetic only, there must be at least 7 days between injections
• If the first diagnostic injection is unsuccessful, a second diagnostic injection may be performed at a different spinal level or with a change in technique (e.g., from an intra-articular facet injection to a medial branch nerve block) given there is a question about the pain generator or evidence of multi-level pathology

Therapeutic Phase

• Facet joint injections may only be repeated after the initial diagnostic phase if the individual has had at least 50% pain relief or significant documented functional improvement for a minimum of 2 months before each therapeutic injection 
• The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 to 10 related to the requested spinal region 
• The individual is engaged in ongoing active conservative treatment* unless the medical reason this treatment cannot be done is clearly documented (8)
  • Diagnostic injections within 1 month of the previous injection do not require documentation of ongoing active conservative therapy
• The diagnostic phase, a maximum of 2 procedures may be performed. Repeat diagnostic injections after prior radiofrequency neurolysis are allowable if there is a question about the pain generator, different levels are to be targeted, or if there is surgery in the same spinal region. 
• A maximum of 4 facet injections may be performed in a 12-month period per spinal region (except under unusual circumstances, such as a recurrent injury) 
• If different spinal regions are being treated, injections should be administered at intervals of no sooner than 7 days unless a medical reason is provided to necessitate injecting multiple regions on the same date of service (see NOTE) Medical Necessity)

NOTE: Radiofrequency neurolysis procedures should be considered in individuals with a successful medial branch nerve block (at least 70% pain relief or improved ability to function), but with insufficient sustained relief (less than 2-3 months improvement).

EXCLUSIONS
These requests are excluded from consideration under this guideline:
Sacral lateral branch blocks (S1, S2, S3)
Atlantoaxial joint injections (C1-2)
Occipital nerve blocks
Hardware injection or block for diagnosis or treatment of post-surgical or other spine pain

CONTRAINDICATIONS^(3,5)
Although there are no absolute contraindications there are relative contraindications that include;

• Active systemic or spinal infection
• Skin infection at the site of needle puncture
• Inability to obtain percutaneous access to the target facet joint
• Medication or contrast agent allergy

HTCC Coverage Determination:
Spinal injections are a covered benefit with conditions.
HTCC Reimbursement Determination:
Limitations of Coverage:*

• Therapeutic epidural injections in the lumbar or cervical-thoracic spine for chronic pain are a covered benefit when all of the following conditions are met: 
  • For treatment of radicular pain; 
  • With fluoroscopic guidance or CT guidance; 
  • After failure of conservative therapy; 
  • No more than two without clinically meaningful improvement in pain and function; and
  • Maximum of three in six months. 
• Therapeutic sacroiliac joint injections for chronic pain is a covered benefit when all of the following conditions are met: 
  • With fluoroscopic guidance or CT guidance; 
  • After failure of conservative therapy; and 
  • No more than one without clinically meaningful improvement in pain and function, subject to agency review.

* This coverage policy does not apply to those with a known systemic inflammatory disease such as: ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis.

Non-Covered Indicators:
Therapeutic medial branch nerve block injections, intradiscal injections and facet injections are not a covered benefit.

Medical Necessity
Medical necessity management for paravertebral facet interventions includes an initial evaluation including history and physical examination and a psychosocial and functional assessment. The following must also be determined¹:

• Nature of the suspected organic problem
• Non-responsiveness to conservative treatment*
• Level of pain and functional disability
• Conditions which may be contraindications to paravertebral facet injections
• Responsiveness to prior interventions

It is generally considered not medically necessary to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient). Different types of injections in the same spinal region (cervical, thoracic, or lumbar) should not be done on the same day with the exception of a facet injection and ESI performed during the same session for a synovial cyst confirmed on imaging.

Conservative Treatment* ⁷
Non-operative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected spinal region.

• Active components
  • Physical Therapy
  • Physician-supervised home exercise program**
  • Chiropractic Care
• Inactive Modalities
  • Medications (e.g., NSAIDs, steroids, analgesics)
  • Injections (e.g., epidural steroid injection, selective nerve root block)
  • Medical Devices (e.g., TENS unit, bracing)

Home Exercise Program (HEP)**⁽¹⁰⁾
The following two elements are required to meet conservative therapy guidelines for HEP: 

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor

AND

• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises).

Definitions ^3,5
Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck, and shoulders.

Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting individuals for controlled local anesthetic blocks of either the medial branches or the facet joint itself. 

Facet joint interventions include intraarticular injections and medial branch nerve blocks in the lumbar, cervical, and thoracic spine. Prior to performing this procedure, shared decision-making between patient and physician must occur, and the patient must understand the procedure and its potential risks and results. Facet joint injections or medial branch nerve blocks require guidance imaging.

References

1. Manchikanti L, Kaye A D, Soin A, Albers S L, Beall D et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain physician. 2020; 23: S1-S127. 
2. Rana S, Pradhan A, Casaos J, Mozaffari K, Ghodrati F et al. Lumbar spinal ganglion cyst: A systematic review with case illustration. Journal of the neurological sciences. 2023; 445: 120539. 
3. Le D, Alem N. Facet Joint Injection. StatPearls [Internet]. 2023; https://www.ncbi.nlm.nih.gov/books/NBK572125/. 
4. Nisolle M, Ghoundiwal D, Engelman E, El Founas W, Gouwy J et al. Comparison of the effectiveness of ultrasound-guided versus fluoroscopy-guided medial lumbar bundle branch block on pain related to lumbar facet joints: a multicenter randomized controlled non-inferiority study. BMC anesthesiology. 2023; 23: 76. 
5. Sayed D, Grider J, Strand N, Hagedorn J M, Falowski S et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. Journal of pain research. 2022; 15: 3729-3832. 
6. Ashmore Z M, Bies M M, Meiling J B, Moman R N, Hassett L C et al. Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis. Pain reports. 2022; 7: e1008. 
7. Cohen S P, Bhaskar A, Bhatia A, Buvanendran A, Deer T et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional anesthesia and pain medicine. 2020; 45: 424-467. 
8. Hurley R W, Adams M C B, Barad M, Bhaskar A, Bhatia A et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain medicine (Malden, Mass.). 2021; 22: 2443-2524. 
9. Washington State Health Care Authority. Health Technology Clinical Committee Coverage Topic 20160318B – Spinal Injections. 2016; https://www.hca.wa.gov/assets/program/spinal_injections-rr_final_findings_decision_060216.pdf. 
10. Qaseem A, Wilt T J, McLean R M, Forciea M A, Denberg T D et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine. 2017; 166: 514-530.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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