ModifiedAmbetter NevadaPolicy CP.MP.171

Facet Joint Interventions

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Clinical coverage criteria for diagnostic and therapeutic facet joint injections and radiofrequency neurotomy for cervical and lumbar regions for Ambetter Nevada members; includes coding guidance and limitations. Applies to providers requesting authorization and performing these procedures.

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ModifiedAmbetter NevadaPolicy CP.MP.171

Facet Joint Interventions

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Policy Summary

PayerAmbetter Nevada

PolicyFacet Joint Interventions

Policy CodePolicy CP.MP.171

Change TypeCriteria revisions, coding removals, threshold updates

Effective Date

Next Review Date

Key ActionObtain prior authorization and document ≥4 weeks physical therapy or prescribed home exercise, ≥3 weeks NSAID trial, ≥3 months pain duration, imaging, and ≥80% diagnostic block pain relief before neurotomy.

SourceLink

POLICY UPDATE CHANGES

Clarifying language added to specify diagnostic facet joint injections and to update physical therapy requirement to ≥ four weeks or prescribed home exercise program.

Pain relief threshold for diagnostic and confirmatory blocks updated from >75% to ≥80%; repeat neurotomy interval updated from ≥4 months to ≥6 months.

CPT codes 0214T, 0215T, 0217T, and 0218T removed from coding table; ultrasound-guided CPTs remain listed as not supporting coverage.

Updated Criteria I.A.1.b.i. regarding physical therapy.

Removed Criteria I.A.1.b.ii. regarding activity modification.

Updated Criteria I.A.1.c. to include notation about facet joint synovial cyst.

Coding and descriptions reviewed; references reviewed and updated.

≥ 3 monthsmin pain duration

≥ 4 weeksPT / home exercise

≥ 80%diagnostic block relief

≤ 3max levels per session

≥ 6 monthsrepeat neurotomy interval

Annualreview frequency

Coverage Criteria — When Interventions Are Medically Necessary

Medical necessity criteria and exclusions

Diagnostic facet joint injections are covered when ALL of the following are met:

Diagnostic Facet Joint Injections (lumbar/cervical)

Symptom duration: Intermittent or continuous back or neck pain that interferes with activities of daily living (ADLs)≥ 3 months
Conservative therapy: Failed to respond to conservative therapy within the past year, including: ≥ four weeks physical therapy or prescribed home exercise program (or documented inability to tolerate); NSAIDs ≥ three weeks or NSAIDs contraindicated/not tolerated
Physical therapy or prescribed home exercise program is not necessary in the presence of a facet joint synovial cyst causing nerve root compression with moderate to severe radicular pain and associated functional limitations.
Clinical and imaging: Clinical findings suggest facet joint syndrome and imaging studies show no other obvious cause of the pain (e.g., fracture, tumor, infection, extraspinal lesion); pain is not associated with radiculopathy or myelopathy except radiculopathy caused by a facet joint synovial cyst
Levels: No more than three spinal levels (unilateral or bilateral) are to be treated at the same session
Confirmatory block: If a second injection is required it is performed at the same level(s) to confirm a positive clinical response of ≥80% pain relief to the initial injection; injections should be given at least two weeks apart
If the first controlled medial branch block/facet joint injection has <80% pain relief, a second block at the same level is not medically necessary.

Facet joint injections of the thoracic region are not medically necessary because effectiveness has not been established. Similarly, conventional radiofrequency neurotomy of thoracic facet joints is not medically necessary for the thoracic region due to insufficient evidence supporting effectiveness.

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance), and to applicable state and federal requirements and Health Plan-level administrative policies and procedures.

Pulsed radiofrequency neurotomy of the facet joints is considered not medically necessary because current evidence is insufficient and primarily based on retrospective and case series studies. In addition, CPT codes for ultrasound-guided facet injections (e.g., 0213T, 0216T) do not support coverage criteria due to limited evidence for ultrasound guidance.

Coding Guidance and Code Lists

Covered CPT Codes for facet injections (image guidance)CPTCovered

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	… cervical or thoracic; second level (List separately in addition to code for primary procedure).
64492	… cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure).
64493	… lumbar or sacral; single level.
64494	… lumbar or sacral; second level (List separately in addition to code for primary procedure).
64495	… lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).

Covered CPT Codes for neurotomy/denervationCPTCovered

64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint.
64634	… cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure).
64635	… lumbar or sacral, single facet joint.
64636	… lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).

CPT codes that do not support coverage criteria (ultrasound guidance)CPTNot Covered

0213T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level.
0216T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level.

inv-08: Diagnostic block pain relief threshold — ≥ 80% pain relief

Diagnostic pain relief threshold≥ 80% pain relief from a diagnostic medial branch block or facet joint injection to be considered a positive response

Confirmatory block timingIf a second (confirmatory) injection is performed it must be at the same level(s) and given at least two weeks after the initial injection

Consequence of <80% responseIf the first block provides <80% pain relief, a second block at the same level is not considered medically necessary

inv-09: Repeat neurotomy durability requirement — ≥ 50% pain relief for at least six months

Durability requirement for repeat neurotomyRepeat radiofrequency neurotomy allowed only if prior treatment provided ≥ 50% pain relief for at least six months with associated functional improvement

What Providers Must Do (Prior Auth, Documentation, Denial Triggers)

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed facet joint injection and conventional radiofrequency neurotomy CPT codes. Providers must obtain prior authorization per payer rules before scheduling these procedures.

Obtain prior authorization for diagnostic and therapeutic facet joint injections and for conventional radiofrequency neurotomy.
Verify prior authorization requirements with Ambetter Nevada before performing services.

Note

Verify Coverage and Contract Conditions

Providers should verify member coverage and benefits and ensure the requested service is consistent with the member's contract and any Health Plan administrative policies. Coverage is subject to the terms, conditions, exclusions and limitations of the member's evidence of coverage and applicable state and federal requirements.

Confirm member eligibility and benefits prior to authorization and service date.
Coverage decisions are subject to contract terms, exclusions, limitations, and regulatory requirements.

Conservative Care Required Before Diagnostic Injections

Must have failed conservative therapy prior to diagnostic injections

Conservative therapy must be documented and failed prior to diagnostic injections:

Conservative Therapy Requirements

Physical therapy/home exercise: ≥ four weeks physical therapy or prescribed home exercise program, or documentation of inability to tolerate
Exceptions allowed when a facet joint synovial cyst is present causing nerve root compression with moderate to severe radicular pain and associated functional limitations.
NSAID trial: Nonsteroidal anti-inflammatory drugs (NSAIDs) for ≥ three weeks, or documentation that NSAIDs are contraindicated or not tolerated

Adhere to updated physical therapy/home exercise requirements prior to certain facet joint interventions as specified in policy criteria.

Follow the policy's updated physical therapy/home exercise requirement prior to certain facet joint interventions:

Limits on Diagnostic Blocks and Repeat Neurotomy

inv-25: Diagnostic blocks and repeat neurotomy — Frequency limits and conditions

Diagnostic block frequencyUp to two controlled medial branch blocks or facet joint injections may be performed (diagnostic) in the lumbar and cervical regions

Confirmatory block requirementIf a second injection is required it must be at the same level(s) to confirm ≥80% pain relief, with injections at least two weeks apart

Repeat neurotomy allowanceRepeat radiofrequency neurotomy is allowed after at least six months if prior neurotomy provided ≥50% pain relief for at least six months and other criteria are met

Level limit for bothNo more than three spinal levels (unilateral or bilateral) may be treated per session for diagnostic blocks or repeat neurotomy

Imaging and Guidance Requirements for Procedures

Billing Rule

Use fluoroscopy or CT image guidance for covered procedures

Perform facet joint injections and conventional radiofrequency neurotomy under fluoroscopy or CT guidance; image guidance is specified in the CPT descriptions supporting coverage.

CPT codes 64490–64495 and 64633–64636 specify image guidance (fluoroscopy or CT).
Ultrasound guidance has limited/inconclusive evidence and ultrasound-guided CPTs do not support coverage.

Note

Review national guidelines and Medicare LCDs/NCDs for imaging guidance

Policy references national guidelines and CMS/Medicare LCDs for imaging guidance; providers should review the cited guidelines and applicable LCDs/NCDs to ensure imaging choices align with current recommendations.

See referenced guidelines (e.g., Chou et al., NASS) and applicable Medicare LCDs/NCDs for imaging recommendations.

Services Not Covered / Not Medically Necessary

NOT COVERED: Thoracic facet joint injections and conventional radiofrequency neurotomy of thoracic facet joints are not medically necessary/not established because effectiveness for these thoracic procedures has not been demonstrated in the available evidence.

Definitions — Procedures and Terms

inv-20: Diagnostic facet injection — Diagnostic medial branch block / facet joint injection

DefinitionDiagnostic medial branch block / facet joint injection performed to assess whether facet joints are the source of neck or back pain

Imaging guidanceRecommended to be performed under fluoroscopy or CT guidance; evidence for ultrasound guidance is limited and inconclusive

Role in care pathwayUsed after conservative therapies have failed to help determine candidacy for therapeutic procedures such as radiofrequency neurotomy

inv-21: Radiofrequency neurotomy — Conventional radiofrequency neurotomy definition and use after successful diagnostic blocks

DefinitionConventional radiofrequency neurotomy (radiofrequency ablation) is thermal lesioning of medial branch nerves to denervate facet joints and reduce pain

Indication after blocks

Background and Clinical Rationale

Facet (zygapophyseal) joint pathology is a common cause of chronic axial low back and neck pain. Diagnosis frequently relies on the analgesic response to diagnostic medial branch blocks or facet joint injections; a positive diagnostic block response (typically defined in this policy as ≥ 80% pain relief) is used to identify patients who may benefit from longer-term treatments such as conventional radiofrequency neurotomy. Evidence supports performing facet interventions with image guidance (fluoroscopy or CT) rather than ultrasound.

Policy Summary

PayerAmbetter Nevada

PolicyFacet Joint Interventions

Policy CodePolicy CP.MP.171

Change TypeCriteria revisions, coding removals, threshold updates

Effective Date

Next Review Date

SourceLink

On This Page

Documentation neededRecord of prior neurotomy pain relief magnitude and duration must be provided to support repeat procedure

Functional improvementDurability criterion includes associated functional improvement following the previous treatment

inv-10: Minimum interval for repeat radiofrequency neurotomy — At least six months since previous treatment

Minimum intervalAt least six months must have elapsed since the previous radiofrequency neurotomy before a repeat procedure is medically necessary

Interval applies to regionsInterval requirement applies to repeat neurotomy in the lumbar or cervical regions

Level limits remainRepeat procedures are subject to the same per-session level limit (no more than three spinal levels unilateral or bilateral)

Denial Risk

Denial Triggers

Requests may be denied if the clinical criteria are not met or documentation is insufficient. Common triggers for denial include inadequate duration of symptoms and lack of required conservative therapy.

Pain duration less than 3 months (criterion I.A.1.a).
Lack of documented conservative therapy (e.g., <4 weeks physical therapy or home exercise program) when required.
Absence of required diagnostic block response prior to radiofrequency neurotomy.

Documentation Required

Documentation and Compliance

Providers must document adherence to the clinical policy criteria and submit complete records with authorization requests. Documentation should include symptom duration, prior conservative treatments, diagnostic block responses, and imaging/clinical findings.

Document back or neck pain lasting ≥ three months and how it interferes with ADLs.
Document failure to respond to conservative therapy within the past year, including ≥4 weeks of physical therapy or a prescribed home exercise program, or reason why not tolerated.
For radiofrequency neurotomy, document ≥80% pain relief from two diagnostic medial branch blocks (initial) and duration/degree of relief for repeat procedures.
Include imaging and clinical findings that support facet joint syndrome and exclude other causes (e.g., fracture, tumor, infection).

Step Therapy

Conservative-First and Diagnostic Block Step

A stepwise, conservative-first approach is required. Diagnostic medial branch blocks are required before therapeutic radiofrequency neurotomy, and therapeutic injections require prior positive diagnostic blocks.

Conservative therapy (physical therapy/home exercise, NSAIDs, etc.) first.
If conservative therapy fails, up to two controlled diagnostic medial branch blocks/facet joint injections may be performed (criteria apply).
Positive response to two diagnostic medial branch blocks (≥80% pain relief) is required before initial radiofrequency neurotomy.

Step Therapy

Conservative Therapy Prior to Intervention

Conservative therapy must be tried and documented prior to interventional procedures unless contraindicated. The policy specifies physical therapy or a prescribed home exercise program for at least four weeks as part of conservative management.

Document ≥4 weeks of physical therapy or a prescribed home exercise program, or document inability to tolerate.
Document use of NSAIDs for ≥3 weeks or reason for contraindication/intolerance.
Exceptions: documented facet joint synovial cyst with nerve root compression and moderate to severe radicular pain may alter physical therapy requirement per note in criteria.

Adherence to updated PT/home exercise requirements: Providers must document adherence to the revised Criterion I.A.1.b.i., which requires ≥ four weeks of physical therapy or a prescribed home exercise program prior to diagnostic facet joint injections unless the member cannot tolerate therapy or a policy-specified exception applies

A specific exception is noted for members with a facet joint synovial cyst causing nerve root compression and moderate to severe radicular pain; in that situation physical therapy or prescribed home exercise program is not necessary.

Review updated evidence on ultrasound versus fluoroscopy/CT as needed.

Medically necessary when there is a positive response to two diagnostic controlled facet joint injections/medial branch blocks with ≥80% pain relief

Guidance and evidencePerformed under fluoroscopy or CT; conventional radiofrequency is recommended over pulsed radiofrequency due to limited evidence for pulsed techniques

inv-22: Facet joint interventions — Procedures to diagnose or treat zygapophysial joint pain

Scope of proceduresFacet joint interventions are procedures performed to diagnose or treat pain originating from zygapophysial (facet) joints, including diagnostic medial branch blocks, therapeutic facet injections, and radiofrequency neurotomy

Imaging preferenceInterventions are recommended to be performed under fluoroscopy or CT guidance; ultrasound guidance has limited/inconclusive evidence

Therapeutic outcome timeframeTherapeutic facet joint injections may provide pain relief typically lasting two to six months, and longer-term effectiveness is uncertain