CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

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Form and authorization requirements for requesting authorization for diagnostic or therapeutic facet joint injections for BlueCross BlueShield of Tennessee commercial members; intended for providers submitting requests and documentation for non-urgent pain management injections.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with imaging, office visit notes, conservative treatment history, dates/levels of prior injections, and anticipated date of service.

SourceLink

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with imaging, office visit notes, conservative treatment history, dates/levels of prior injections, and anticipated date of service.

SourceLink

Coverage Criteria and Authorization Support

Authorization support criteria

Form collects information to support medical necessity; coverage contingent on documentation of the following

General requirements: Procedure type selected (diagnostic or therapeutic); requested procedure code, modifiers (LT/RT/50) and quantity documented; spine levels and side of planned injections specified; anticipated date of service and primary diagnosis code provided

Form requires specifying side, levels, modifiers, quantity, and anticipated date of service

Clinical presentation: Procedure is being requested for back or neck pain occurring daily; documentation that other sources of pain have been ruled out; presence or absence of radiculopathy documented (radiculopathy is noted as an item; exception allowed if due to lumbar facet joint synovial cyst)

Form captures symptom checkboxes including radiculopathy exception

Conservative care: Documentation of conservative treatments attempted such as NSAIDs, analgesics, other medications (steroids, muscle relaxants, neuropathic agents), rest/activity modification, physical therapy, or manipulation; duration of conservative care indicated as either less than three (3) months or three (3) months or longer3 months option collected

Form captures both type(s) of conservative treatment and duration

Prior procedures and imaging: Dates and levels of all previous injections provided; if therapeutic injection, number of previous facet joint injections within the past 12 months indicated (0,1,2,3,4+); prior spinal fusion at any levels reported; imaging records submitted with requestprevious injections within 12 months are queried

Form requests dates/levels of prior injections and prior fusion history

Procedure logistics and safety: Indicate whether fluoroscopic guidance will be used and facility location; report relevant comorbidities/contraindications (allergy, infection, uncontrolled hypertension, CHF, diabetes, bleeding disorder/anticoagulant use, neurogenic claudication); note if another injection/procedure is planned within three (3) daysfluoroscopy choice recorded

Form asks explicitly about fluoroscopy and lists safety/contraindication items

The authorization form includes a checkbox list for presenting conditions and specifically lists Radiculopathy as a selectable item. The form notes an exception for radiculopathy caused by a facet joint synovial cyst in the lumbar spine.

The form asks whether a planned facet joint injection is being scheduled within three (3) days of another procedure (for example, epidural, sacroiliac joint injection, lumbar sympathetic block, or trigger point injections) and flags this circumstance for review.

Procedure Codes and Lookback

Applicable procedure codesmixed

0213T	listed on form
0214T	listed on form
0215T	listed on form
0216T	listed on form
0217T	listed on form
0218T	listed on form
64490	listed on form
64491	listed on form (use LT/RT modifiers only, not 50)
64492	listed on form (use LT/RT modifiers only, not 50)
64493	listed on form

1–10 of 12

1/2

Covered CPT/HCPCS codes (listed on form)mixed

0213T	listed on form
0214T	listed on form
0215T	listed on form
0216T	listed on form
0217T	listed on form
0218T	listed on form
64490	listed on form
64491	listed on form (use LT/RT modifiers only, not 50)
64492	listed on form (use LT/RT modifiers only, not 50)
64493	listed on form

1–10 of 12

1/2

Previous facet injections lookback — within past 12 months

Lookback periodPrevious facet joint injections are queried within the past 12 months

Response optionsNo previous injection; 1; 2; 3; 4 or more

Documentation requiredDates and levels of all previous injections must be provided on the form

Submission, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed CPT/HCPCS codes for commercial members. Submit the completed authorization form and all supporting records (imaging, office visit notes, attempted conservative treatments, etc.). Failure to submit appropriate relevant medical records may result in determination delays and denials.

Affected codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495 (64491, 64492, 64494, 64495 use LT/RT modifiers only; do not use modifier 50)
Submit via Availity or fax to Utilization Management at 423-800-5302; phone: 866-747-0586

Documentation Required

Conservative Treatment Documentation Required

The authorization form requires documentation of the duration and types of conservative treatments attempted. Indicate how long conservative treatments were tried (less than 3 months or 3 months or longer) and which treatments were attempted.

Definitions and Therapy Types

Therapeutic Facet Joint Injection — distinguishes therapeutic vs diagnostic nerve root blocks and target areas

Procedure type selectionForm requires selecting either Diagnostic nerve root block(s) OR Therapeutic Facet Joint (intraarticular) or medial branch injection

Distinction notedTherapeutic injections (intraarticular/medial branch) are separate from diagnostic nerve root blocks on the request form

Procedure details to reportRequested procedure code, modifier (LT/RT/50), quantity, and treated spine levels must be documented

Conservative treatments — non-invasive measures documented on the form (medications, PT, activity modification, etc.)

Types of conservative treatmentsMedication - NSAIDs; Medication - analgesics; Medication - other (steroids, muscle relaxants, nerve pain medication, etc.); Rest or activity modification; Physical therapy; Manipulation

Conservative Therapy Duration and Options

Conservative treatment duration and types

Duration and types of conservative treatments must be indicated on the form — select one duration and list applicable treatments

Duration options: Duration of conservative treatments selected as either: Less than three (3) months OR Three (3) months or longer3 months

Form provides these two mutually exclusive duration options

Types of conservative treatments: One or more of the following must be indicated as attempted: Medication - NSAIDs; Medication - analgesics; Medication - other (steroids, muscle relaxants, nerve pain medication, etc.); Rest or activity modification; Physical therapy; Manipulation

Form captures multiple treatment types via checkboxes

Reporting Prior Facet Joint Injections

Therapeutic facet joint injection — prior injections queried

Applicable when therapeutic injection selectedIf therapeutic injection, the form requires reporting the number of prior facet joint injections performed within the past 12 months

Answer choicesNo previous injection (first treatment); One (1); Two (2); Three (3); Four (4) or more

Follow-up fieldProvider must provide dates and levels of all previous injections on the form

Imaging and Supporting Documentation

Note

Include imaging with authorization form

When requesting authorization for facet joint injections, submit imaging with the authorization form and include dates/levels of prior injections and prior spinal fusion history as part of the supporting records.

Form explicitly asks for imaging and for dates and levels of all previous injections
Indicate whether prior spinal fusion exists at any levels

Background

Facet joint injections may be requested as either diagnostic nerve root block(s) or therapeutic intraarticular facet joint/medial branch injections. The authorization form captures clinical presentation, prior spine surgery and injections, procedural details (such as levels and use of fluoroscopy), and whether the request is diagnostic versus therapeutic to support medical-necessity review.

Not Covered / Exclusions

The form does not list any specific procedures or indications as explicitly “not covered.” However, it documents conditions and contraindications (for example, active infection, allergy to the medication, uncontrolled hypertension, bleeding disorder/anticoagulant use) that may lead to denial, and it flags injections planned within three (3) days of other procedures as a review consideration. Incomplete or missing documentation on the form may also result in denial.