Prior Authorization Required

Prior authorization is required by Arizona Complete Health for diagnostic and therapeutic facet joint injections and conventional radiofrequency neurotomy when the medical necessity criteria in this policy are met. Submit a prior authorization request before performing these procedures to avoid claim denial.

• Applies to diagnostic facet injections, therapeutic facet injections, and conventional radiofrequency neurotomy performed under fluoroscopy or CT guidance.
• Limit of one procedure per visit applies; no more than three spinal levels (unilateral or bilateral) treated at the same session.

Authorization Follows Updated Criteria

Prior authorization decisions will follow the updated clinical criteria (see Criteria I.A.1.b.i. and related sections). If the member meets the revised criteria (for example, updated physical therapy requirements or exceptions for facet joint synovial cyst), include documentation that aligns with the current policy language.

• Reference the updated Criteria I.A.1.b.i. for physical therapy/home exercise documentation and the note regarding facet joint synovial cysts.
• Removal of prior criteria (e.g., I.A.1.b.ii. regarding activity modification) means previously acceptable documentation based on that removed criterion may no longer support authorization.

Policy Changes May Affect Authorization

Policy changes may affect prior authorizations. When criteria are removed or revised, prior authorization may be denied if the required supporting documentation for the current criteria is not provided.

• Example: Removal of Criterion I.A.1.b.ii. (activity modification) may result in denial if providers rely on that documentation instead of the current requirements.
• Always include documentation meeting the current policy effective at time of request; the Health Plan may change, amend, or withdraw policies at any time.

Document Therapy, Response, and Coding

Document adherence to the policy's therapy and coding requirements when submitting prior authorization and claims. Include duration of pain, conservative therapy details, responses to diagnostic injections, and the specific CPT codes used.

• Document pain duration (≥ 3 months) and clinical findings consistent with facet joint pain.
• Document failure of conservative therapy: ≥4 weeks physical therapy or prescribed home exercise program (or documented inability to tolerate), and ≥3 weeks of NSAIDs or documented contraindication/intolerance.
• Include documentation of response to diagnostic controlled facet injections when required (e.g., ≥ 80% relief for radiofrequency neurotomy eligibility; ≥50% relief for repeat therapeutic procedures).
• Support billing with fluoroscopy or CT image-guided CPT codes (e.g., 64490–64495 for facet injections; 64633–64636 for neurotomy) and avoid codes for unsupported guidance methods.

Conservative Therapy Prerequisite

Conservative therapy must be documented before authorization of diagnostic facet injections except in defined exceptions (e.g., facet joint synovial cyst causing nerve root compression with moderate to severe radicular pain and functional limitations).

• At minimum, document ≥ four weeks of physical therapy or a prescribed home exercise program, or document inability to tolerate such therapy.
• Document ≥ three weeks of NSAID therapy or a contraindication/intolerance to NSAIDs.
• If a facet joint synovial cyst is present causing nerve root compression with moderate–severe radicular pain, the physical therapy/home exercise requirement may be waived; document imaging and clinical correlation.

Perform facet procedures with fluoroscopy or CT guidance

Facet joint injections and radiofrequency neurotomy must be performed under fluoroscopy or CT guidance; document the imaging modality used in the procedure note to meet policy imaging requirements.

• Policy statement: interventions are recommended and required to be performed under fluoroscopy or CT guidance.
• Include image-guidance details in operative report and billing to support covered CPT codes.

Refer to cited imaging guidelines and evidence reviews

The policy references diagnostic imaging guidelines and evidence reviews (ASIPP, CMS LCDs, NASS, Cochrane, and other systematic reviews); consult the full policy references section for detailed guidance on imaging and evidence that informed coverage decisions.

• Key references include ASIPP guidelines, CMS local coverage determinations, NASS guidelines, and Cochrane reviews cited in the policy.