CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

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

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12procedure codes referenced on form

12 molookback for previous facet injections

3 moconservative treatment duration options

Availityonline submission channel

Coverage Criteria and Authorization Support

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Duration options: Less than three (3) months; Three (3) months or longer
Conservative treatments to document: NSAIDs, analgesics, other medications (steroids, muscle relaxants, neuropathic pain meds), rest/activity modification, physical therapy, manipulation
Document that other sources of pain were ruled out, presence/absence of radiculopathy, and functional limitations due to pain
Include patient's pain level (scale 6–10 as applicable)

Documentation Required

Required Submission Materials

Submit the completed authorization form with all relevant medical records. Required submission materials include imaging, office visit notes, documentation of attempted conservative treatments, prior injection history (dates and levels), and any comorbidity or contraindication information. By submitting, you confirm all pertinent clinical information has been provided.

Imaging studies and reports
Office visit notes documenting history, exam, and conservative care attempts
Documentation of prior facet injections (dates, levels, number in past 12 months)
Any relevant labs or notes regarding infection, bleeding disorders, anticoagulant use, uncontrolled hypertension, CHF, diabetes, or allergies
Submit online via Availity or fax to 423-800-5302; call Utilization Management at 866-747-0586 for questions

Denial Risk

Incomplete Documentation May Cause Denial

Failure to submit appropriate and relevant medical records may result in denial or delay of the authorization decision.

Incomplete documentation (missing imaging, lack of conservative treatment details, or absent prior injection history) increases risk of denial or processing delays

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

Duration reportingForm asks how long conservative treatments were attempted: Less than three (3) months OR Three (3) months or longer

Clinical context captureForm collects whether pain is daily, absence of radiculopathy, and if other pain sources have been ruled out to support conservative care documentation

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