CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

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Form and requirements for prior authorization of facet joint injections and related pain-management injection CPT codes for BlueCross BlueShield of Tennessee commercial members; used by ordering/rendering providers to submit clinical information and supporting records.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyFacet joint injection authorization request — clinical coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with relevant medical records (imaging, office notes, conservative treatment attempts, dates/levels of prior injections) to support medical necessity.

SourceLink

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pain Management Facet Joint Injection Authorization Request Form — Coverage Criteria

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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

PolicyFacet joint injection authorization request — clinical coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

Coverage criteria and exclusions

Medical necessity elements collected

Form collects elements used to establish medical necessity; covered when documentation provided supports the following

Core documentation: Completed authorization form plus relevant medical records (imaging, office visit notes, documentation of attempted conservative treatments)

Supports medical necessity review

Procedure type: Diagnostic nerve root block(s) OR Therapeutic facet joint (intraarticular) or medial branch injection

Provider to select procedure and levels

Conservative treatments attempted documented; provider must indicate which treatments were tried (NSAIDs, analgesics, other medications such as steroids/muscle relaxants/nerve pain meds, rest/activity modification, physical therapy, manipulation)3 months

Form asks duration as Less than three (3) months OR Three (3) months or longer

Fluoroscopy: Indicate whether injection will be performed with fluoroscopic guidance

Fluoroscopy option is asked on the form

Diagnostic block response for therapeutic injections: If therapeutic injection requested, document percent pain relief from diagnostic nerve block (0-24%, 25-49%, 50-74%, 75-100%)>=50% relief supports therapeutic benefit

Used to support decision for therapeutic injection

Repeat therapeutic injections: For repeat therapeutic injections, documentation must indicate whether prior therapeutic injection produced greater than 50% improvement in pain and function for ten (10) weeks or longer>50% for >=10 weeks

Form queries number and dates/levels of prior injections within the past twelve (12) months

The authorization form requires screening for specific contraindications and comorbidities prior to approval. Providers must indicate if the member has any of the following: allergy to the medication being administered, infection (systemic or at the injection site), uncontrolled hypertension, congestive heart failure, diabetes, bleeding disorder or anticoagulant use, planned nearby injections within three (3) days of the facet joint injection, or neurogenic claudication. The form also includes an option to select None if none of these apply.

The form explicitly screens for radiculopathy as a contraindication. An exception is noted: radiculopathy is not listed as acceptable unless it is caused by a lumbar facet joint synovial cyst, in which case it would not be treated as the exclusion.

Procedure codes and coding details

Covered CPT/HCPCS codes referenced on formmixed

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

inv-05: Previous injection interval — within the past twelve (12) months

Look-back intervalWithin the past twelve (12) months

Applicable procedureFacet joint injection (asks whether a previous facet joint injection was performed)

Provider must supplyDates and levels of all previous injections within the 12‑month period

Authorization and submission requirements for providers

Prior Authorization

Prior authorization required for listed CPT/HCPCS codes

Prior authorization is required for the listed CPT/HCPCS codes for BlueCross BlueShield of Tennessee commercial members; submit this form and supporting records for review.

Codes listed on form: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495
Use LT and/or RT modifiers for codes 64491, 64492, 64494, 64495 (do not use 50)

Step Therapy

Document prior injection benefit (>50% for ≥10 weeks) for repeats

For requests for a repeat therapeutic injection, documentation must indicate whether the prior therapeutic injection provided greater than 50% improvement in pain and function for ten (10) weeks or longer.

Select Yes or No for: prior injection produced >50% improvement in pain and function for ≥10 weeks

Policy background and intent

This authorization form collects clinical details to document medical necessity for diagnostic or therapeutic facet joint (intraarticular) and medial branch procedures. It captures comorbidity screening (see contraindications), prior treatments and duration, and response to diagnostic blocks so reviewers can determine whether the requested diagnostic nerve block or therapeutic injection is supported by the submitted clinical information.

Procedure and response definitions

inv-11: Procedures requested — diagnostic nerve root block(s), therapeutic facet joint (intraarticular) or medial branch injection; side/level options

Procedure optionsDiagnostic nerve root block(s); Therapeutic facet joint (intraarticular) or medial branch injection

Side optionsLeft, Right, or Bilateral

Spine levelsMultiple selectable levels (C1–C2 through L5–S1) as listed on form

inv-12: Diagnostic nerve block response — records percent pain relief categories (0-24%, 25-49%, 50-74%, 75-100%)

0-24%No diagnostic nerve block completed = 0-24% pain relief

25-49%Diagnostic nerve block recorded as 25-49% pain relief

Conservative therapy attempts required

Conservative treatment attempts and duration

Provider must indicate which conservative treatments have been attempted and the duration.

Duration selection

Duration options: Less than three (3) months OR Three (3) months or longer3 months
Select one

Treatment types: Provider selects all conservative treatments that have been attempted

Options include: Medication - NSAIDs; Medication - analgesics; Medication - other (steroids, muscle relaxants, nerve pain medication, etc.); Rest or activity modification; Physical therapy; Manipulation

Limits and look-back for prior injections

inv-14: facet joint injection — asks whether a previous facet joint injection was performed within the past twelve (12) months and number of prior injections

Previous injection performed?Form asks whether a previous facet joint injection was performed within the past twelve (12) months

Number of prior injectionsOptions: No previous injection (first treatment); One; Two; Three; Four or more

Documentation requiredProvider to list dates and levels of all previous injections

Imaging to support requests

Note

Include imaging with the request when available

When available, submit imaging studies as part of the supporting records with the authorization request.

Include relevant imaging and ensure dates/levels correspond to the clinical notes and prior injections section of the form

Exclusions and not-covered considerations

While the form does not list an explicit “not covered” procedures list, it screens out requests when the screened contraindications are present. In particular, presence of radiculopathy is treated as an exclusion unless the radiculopathy is attributable to a lumbar facet joint synovial cyst; when one of the listed contraindications applies, approval may be precluded.