CurrentCentenePolicy CP.MP.171

Facet Joint Interventions (diagnostic and therapeutic injections and radiofrequency neurotomy)

Defines medical necessity criteria for diagnostic and therapeutic facet joint injections and conventional and pulsed radiofrequency neurotomy in cervical and lumbar regions, exclusions for thoracic procedures and pulsed RF, guidance on imaging modality (fluoroscopy/CT), limits per session, and coding implications.

Policy Summary

PayerCentene

PolicyFacet Joint Interventions (diagnostic and therapeutic injections and radiofrequency neurotomy)

Policy CodePolicy CP.MP.171

Change TypeClarified criteria; coding update; interval revision

Effective Date

Next Review Date

Key ActionDocument ≥ 4 weeks physical therapy or prescribed home exercise (or inability to tolerate) and ≥ 3 weeks NSAID trial or contraindication; include clinical findings and imaging to exclude other causes.

SourceLink

POLICY UPDATE CHANGES

Clarifying language added to Criteria I.A. to specify diagnostic facet joint injections and updates to physical therapy and pain relief thresholds.

Removed several CPT codes (0214T, 0215T, 0217T, 0218T) from coding table and retained ultrasound-guided codes as not supported.

Updated repeat neurotomy criteria interval from at least four months to at least six months.

Added requirement that if second diagnostic injection is required it must be at same level(s) and at least two weeks apart.

CoveredCervical and lumbar: covered with criteria

Not coveredThoracic injections and thoracic RF: not covered

InvestigationalPulsed RF: insufficient evidence

2Up to 2 diagnostic blocks

3Max 3 levels per session

Coverage Summary

Defines medical necessity criteria for diagnostic and therapeutic facet joint injections and conventional radiofrequency neurotomy in the cervical and lumbar regions. Applies when pain has persisted for ≥ 3 months, after conservative care including ≥ 4 weeks of physical therapy or prescribed home exercise (or documented inability to tolerate) and a trial of NSAIDs for ≥ 3 weeks. Diagnostic controlled medial branch blocks are limited to up to two injections and are considered positive with ≥ 80% pain relief; if a confirmatory second injection is needed it must be at the same level(s) at least 2 weeks after the first. Repeat neurotomy requires prior relief of ≥ 50% for at least 6 months. No more than 3 spinal levels (unilateral or bilateral) may be treated at the same session.

Key thresholds

Duration of pain≥ 3 months

Physical therapy/home exercise≥ 4 weeks (or documented inability to tolerate)

NSAID trial≥ 3 weeks (or NSAIDs contraindicated/not tolerated)

Diagnostic pain relief threshold (positive block)≥ 80% pain relief

Repeat neurotomy relief/duration≥ 50% pain relief for at least 6 months required for repeat

Therapeutic injection sustained response≥ 50% pain relief for at least 3 months or ≥ 50% consistent improvement in ADLs

Max spinal levels per sessionNo more than 3 levels (unilateral or bilateral)

Minimum interval between diagnostic injectionsAt least 2 weeks between first and confirmatory injection

Medical Necessity Criteria

General policy

Invasive pain management procedures performed by a physician are medically necessary when the relevant criteria are met, and the patient receives only one procedure per visit, with or without radiographic guidance.

Only one procedure per visit is allowed (with or without radiographic guidance).

I.A Diagnostic Facet Joint Injections (fluoroscopy or CT guidance)

Up to two controlled medial branch blocks/facet joint injections in lumbar and cervical regions when ALL criteria are met:

Intermittent or continuous back or neck pain that interferes with activities of daily living (ADLs) has lasted for ≥ three months.≥ 3 months

ALL of the following

Coding

CPT codes that support coverage criteriaCPTCovered

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	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure).
64492	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT); third and any additional level(s) (List separately in addition to code for primary procedure).
64493	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), lumbar or sacral; single level.
64494	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure).
64495	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).
64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint.
64634	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately).
64635	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint.
64636	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately).

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.

Provider Actions

Documentation Required

Conservative therapy documentation

Document at least four weeks of physical therapy or a prescribed home exercise program (or document inability to tolerate), and a trial of nonsteroidal anti-inflammatory drugs for at least three weeks (or document NSAID contraindication or intolerance). Include clinical findings that suggest facet joint syndrome and imaging that excludes other causes (e.g., fracture, tumor, infection, extraspinal lesion).

Prior Authorization

Confirmation before radiofrequency neurotomy

Before performing an initial conventional radiofrequency (RF) neurotomy, document two diagnostic controlled medial branch/facet joint injections for each region to be treated, with at least ≥ 80% pain relief reported after each diagnostic injection.

Background and Rationale

Facet joint pain is a common contributor to chronic low back and neck pain, but diagnosis is challenging and is often based on the degree of pain relief following diagnostic medial branch blocks rather than on imaging alone.

The evidence supporting intra-articular facet joint injections for long-term benefit is equivocal; improvements after injections are often short term (uncertain beyond two to six months) and overall patient selection and long-term safety remain unclear.

Facet interventions in the thoracic region and pulsed radiofrequency neurotomy are considered not medically necessary because effectiveness has not been established and available studies are limited (few RCTs and mostly low-quality or retrospective series).

Because of these limitations and to improve procedural accuracy, the policy recommends performing facet interventions under fluoroscopy or CT guidance; the evidence for ultrasound guidance is limited and inconclusive and ultrasound-guided codes are not supported.

Evidence thresholds

Diagnostic block positive response threshold≥ 80% pain relief

Repeat neurotomy effectiveness≥ 50% relief for at least 6 months

Medicare Determinations

Name	Number	Effective	Type
Local coverage determination: facet joint interventions for pain management	L38841	2021-04-25 (revised 2024-07-14)	LCD

Revision History

05/25/2025clarifiedLatest

Clarifying language added to Criteria I.A. to specify diagnostic facet joint injections; physical therapy requirement updated to ≥ four weeks (or documented inability to tolerate) with a note that PT/home exercise is not necessary for facet joint synovial cyst causing nerve root compression.

05/25/2025clarifiedLatest

Diagnostic pain relief threshold for a positive controlled medial branch block revised from >75% to ≥ 80%; note added that if first block provides < 80% relief, a second block at the same level is not medically necessary.

Policy Summary

PayerCentene

PolicyFacet Joint Interventions (diagnostic and therapeutic injections and radiofrequency neurotomy)

Policy CodePolicy CP.MP.171

Change TypeClarified criteria; coding update; interval revision

Effective Date

Next Review Date

SourceLink

On This Page

≥ four weeks physical therapy or prescribed home exercise program, or documentation of member/enrollee inability to tolerate.

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.

Nonsteroidal anti-inflammatory drugs (NSAIDs) ≥ three weeks, or NSAIDs contraindicated or not tolerated.≥ 3 weeks

Clinical findings suggest facet joint syndrome, and imaging studies suggest no other obvious cause of the pain (e.g., fracture, tumor, infection, extraspinal lesion), and pain is not associated with radiculopathy (except for radiculopathy caused by a facet joint synovial cyst) or myelopathy.

Physical findings can include low back pain exacerbated on extension and rotation or positive response to facet loading maneuvers.

No more than three spinal levels (unilateral or bilateral) are to be treated at the same session.No more than 3 levels

If a second injection is required, it is performed at the same level(s) to confirm validity of a positive clinical response (i.e., ≥ 80% pain relief) to the initial injection, and injections should be given at least two weeks apart.≥ 80% pain relief; ≥ 2 weeks between injections

A radiofrequency joint denervation/ablation procedure is being considered.

I.A Note on second block

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.< 80% pain relief

I.B Conventional facet joint medial branch radiofrequency neurotomy (fluoroscopy or CT guidance)

Initial and repeat neurotomy in lumbar or cervical regions when ALL criteria are met:

Initial neurotomy (I.B.1)

Neck or back pain present for ≥ three months.≥ 3 months
There was a positive response to two diagnostic controlled facet joint injections/medial branch blocks (at each region to be treated), as indicated by ≥ 80% pain relief.≥ 80% pain relief
No more than three spinal levels (unilateral or bilateral) are to be treated at the same session.No more than 3 levels

Repeat neurotomy (I.B.2)

At least six months have elapsed since the previous treatment.≥ 6 months interval
≥ 50% pain relief was obtained for at least six months, with associated functional improvement, following the previous treatment.≥ 50% relief for ≥ 6 months
No more than three spinal levels (unilateral or bilateral) are to be treated at the same session.No more than 3 levels

I.C Thoracic facet joint injections

Facet joint injections of the thoracic region are considered not medically necessary because effectiveness has not been established.not medically necessary

I.D Therapeutic facet joint injections (fluoroscopy or CT guidance)

Therapeutic injections are medically necessary when ALL criteria are met:

There was a positive response to two diagnostic controlled facet joint injections/medial branch blocks (at each region to be treated), as indicated by ≥ 80% pain relief.≥ 80% pain relief

Subsequent therapeutic facet joint procedures at the same anatomic site result in ≥ 50% pain relief for at least three months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale.≥ 50% relief for ≥ 3 months or ≥ 50% consistent improvement in ADLs

Documentation explains why member/enrollee is not a candidate for radiofrequency neurotomy (such as established spinal pseudarthrosis or implanted electrical device).

No more than three spinal levels (unilateral or bilateral) are to be treated at the same session.No more than 3 levels

I.E Conventional radiofrequency neurotomy of thoracic facet joints

Conventional radiofrequency neurotomy of the facet joints of the thoracic region is considered not medically necessary because effectiveness has not been established.not medically necessary

There is a need for further well-designed, randomized controlled trials to evaluate effectiveness.

I.F Pulsed radiofrequency neurotomy

Pulsed radiofrequency neurotomy of the facet joints is considered not medically necessary due to insufficient evidence from randomized controlled trials and low-quality studies.not medically necessary/insufficient evidence

Available evidence is largely retrospective and further well-designed RCTs are needed.

Billing Rule

Procedure per visit limit

Only one invasive pain management procedure is permitted per visit. Additionally, no more than three spinal levels (unilateral or bilateral) may be treated during the same session.

Denial Risk

Non-covered thoracic procedures and pulsed RF

Claims for thoracic facet joint injections, conventional thoracic radiofrequency neurotomy, and pulsed radiofrequency neurotomy are considered not medically necessary and may be denied, as effectiveness has not been established or evidence is insufficient.

Documentation Required

Therapeutic injection eligibility

For therapeutic facet joint injections, document a prior positive response to two diagnostic controlled medial branch/facet joint injections (each showing ≥ 80% pain relief). For subsequent therapeutic procedures, document objective evidence of sustained benefit (≥ 50% pain relief for at least three months or ≥ 50% consistent improvement in ADLs), or provide documentation explaining why radiofrequency neurotomy is contraindicated.

Billing Rule

Image guidance requirement

Facet interventions should be performed under fluoroscopy or CT guidance. Ultrasound-guided facet injections are not supported by this policy.

64490
64491
64492
64493
64494
64495
64633
64634
64635
64636
0213T
0216T

05/25/2025revisedLatest

Repeat neurotomy criteria interval updated from at least four months to at least six months; repeat treatment requires prior ≥ 50% pain relief sustained for at least six months.

05/25/2025revisedLatest

Coding table cleaned: removed CPT codes 0214T, 0215T, 0217T, and 0218T; ultrasound-guided facet injections (codes 0213T, 0216T) noted as not supported by the policy.

05/25/2025clarifiedLatest

Added requirement that if a second diagnostic injection is required it must be performed at the same level(s) to confirm validity of the initial positive response and injections should be given at least two weeks apart; also specified second block at same level is not necessary if first block provided < 80% relief.