CurrentColorado Rocky Mountain Health PlansPolicy CSNCT0005.08

Facet Joint and Medial Branch Block Injections for Spinal Pain (for North Carolina Only)

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Coverage of diagnostic facet joint injections and medial branch blocks for spinal pain in North Carolina, including criteria for initial and confirmatory injections and exclusions for therapeutic use.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain

Policy CodePolicy CSNCT0005.08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionBefore an initial diagnostic injection, complete at least 4 weeks of conservative care, with pain remaining at 3 or more on a 1–10 scale.

SourceLink

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CurrentColorado Rocky Mountain Health PlansPolicy CSNCT0005.08

Facet Joint and Medial Branch Block Injections for Spinal Pain (for North Carolina Only)

Customize your policy alerts

Sign up for Colorado Rocky Mountain Health Plans Policy CSNCT0005.08 alerts

Get alerted when Policy CSNCT0005.08 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain

Policy CodePolicy CSNCT0005.08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionBefore an initial diagnostic injection, complete at least 4 weeks of conservative care, with pain remaining at 3 or more on a 1–10 scale.

SourceLink

POLICY UPDATE CHANGES

The Medical Records Documentation Used for Reviews section was removed in the 2026 policy update.

NCApplicable state

4 weeksInitial conservative care

≥3/10Pain threshold

2Maximum diagnostic injections at same level and side

0.5 mLMaximum anesthetic volume

≥80%Diagnostic block relief threshold

Medical Necessity and Coverage Criteria

Initial diagnostic injection

Covered as proven and medically necessary when all criteria are met.

Initial diagnostic facet joint injection or medial branch block

Clinical indication
- Pain is exacerbated by facet-loading maneuvers on physical examination, such as hyperextension or rotation.
- Clinical findings and imaging studies suggest no other cause of the pain, such as spinal stenosis with neurogenic claudication, disc herniation with radicular pain, infection, tumor, fracture, or pain related to prior surgery.
- The spinal motion segment is not fused.
Response to conservative care
- Clinically significant improvement has not occurred after conservative care.
- Conservative care has been provided for a minimum of 4 weeks and includes an appropriate combination of medication and activity-based or rehabilitative treatment, such as exercise or physical therapy.Pain remains ≥3/10 after ≥4 weeks of conservative care
A radiofrequency joint denervation or ablation procedure is being considered.

Confirmatory diagnostic injection

Covered as proven and medically necessary when all criteria are met.

The second facet joint injection or medial branch block is administered at the same level and side as the initial block.
Positive response to the initial diagnostic injection
- The initial injection produced at least 50% pain relief for at least the expected minimum duration of the local anesthetic.≥50% pain relief for the expected anesthetic duration
- The response included individualized functional improvement, with demonstrable improvement in physical functions previously limited by facetogenic pain.
A radiofrequency joint denervation or ablation procedure is being considered.

Diagnostic medial branch blocks

NASS diagnostic medial branch block confirmation requires dual blocks at the same location on separate occasions.

Dual diagnostic blocks

Diagnostic medial branch blocks are performed at the same location or locations on two separate occasions.
The blocks are performed sequentially because a single diagnostic anesthetic injection has an unacceptably high false-positive rate.

First-block response before confirmation

The first injection produces at least 80% relief of the primary or index pain.
The onset and minimum duration of relief are consistent with the anesthetic agent used.

Conservative therapy and prognostic response

Apply the following conservative-treatment and prognostic-response criteria.

Lumbar intervention preparation

A 3-month trial of different conservative treatments is completed before lumbar facet interventions.3 months
Conservative treatment may include medications, exercise, heat or cold therapy, massage, acupuncture or spinal manipulation when indicated, nutrition, weight loss, and sleep hygiene.

Cervical prognostic-block preparation

The patient has at least 3 months of neck pain.At least 3 months of neck pain
Conservative management is used before cervical prognostic blocks, including at least a 6-week trial of conservative therapy.At least 6 weeks of conservative therapy

Cervical preprocedural imaging

Obtain the required imaging before performing these upper-cervical joint injections.

Preprocedural imaging

Advanced cervical spine imaging is obtained before an atlanto-occipital or atlanto-axial joint injection to ascertain pathology and guide needle trajectory.CT or MRI before injection

Facet joint injections and medial branch blocks are unproven and not medically necessary when radiofrequency joint denervation or ablation is not being considered as a treatment option at the requested level or levels.

Facet joint injections and medial branch blocks are unproven and not medically necessary when used to treat spinal pain after the diagnostic injections have been completed.

Therapeutic facet joint injections and facet nerve blocks, including medial branch blocks, are unproven and not medically necessary when used to treat chronic spinal pain.

Therapeutic facet joint or medial branch block injections at the cervical, thoracic, or lumbar spinal levels are unproven and not medically necessary because evidence of efficacy and safety is insufficient.

A second facet joint injection or medial branch block is unproven and not medically necessary when the initial injection did not confirm the facet joint as the source of pain.

Facet joint injections and medial branch blocks are unproven and not medically necessary when untreated radiculopathy is present at the same level as the intended diagnostic injection. An exception applies when the radiculopathy is caused by a facet joint synovial cyst.

Facet joint injections and medial branch blocks are unproven and not medically necessary when performed under ultrasound guidance.

A medial branch block is unproven and not medically necessary when the local-anesthetic injection volume exceeds 0.5 mL.

According to ACOEM guidance, therapeutic facet joint injections are not recommended for acute or subacute low back pain or for radicular pain syndromes.

ACOEM moderately recommends against routine therapeutic facet joint injections for chronic nonspecific axial pain.

Therapeutic use of facet joint injections or medial branch blocks is not medically necessary, including treatment of chronic spinal pain, treatment after diagnostic injections are complete, and additional injections after two procedures at the same level and same side.

Therapeutic facet joint or medial branch block injections at the cervical, thoracic, and lumbar spinal levels are not medically necessary because evidence of efficacy and safety is insufficient.

Repeat intra-articular therapeutic facet joint injections are moderately not recommended when a prior injection did not produce lasting functional improvement.

Procedure and Diagnosis Coding

Ultrasound-guided facet and medial branch injection codesCPTNot 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.
0214T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level.
0215T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s).
0216T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level.
0217T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level.
0218T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s).

Fluoroscopy- or CT-guided facet and medial branch injection codesCPT

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 (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level.
64492	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s).
64493	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level.
64494	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level.
64495	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s).

Diagnosis codesICD-10

M47.812	Spondylosis without myelopathy or radiculopathy, cervical region.
M47.813	Spondylosis without myelopathy or radiculopathy, cervicothoracic region.
M47.814	Spondylosis without myelopathy or radiculopathy, thoracic region.
M47.815	Spondylosis without myelopathy or radiculopathy, thoracolumbar region.
M47.816	Spondylosis without myelopathy or radiculopathy, lumbar region.
M47.817	Spondylosis without myelopathy or radiculopathy, lumbosacral region.
M47.819	Spondylosis without myelopathy or radiculopathy, site unspecified.
M47.892	Other spondylosis, cervical region.
M47.893	Other spondylosis, cervicothoracic region.
M47.894	Other spondylosis, thoracic region.

1–10 of 15

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Conservative Care Duration

Minimum durationAt least 4 weeks of conservative care before an initial diagnostic injection.

Applicable procedureInitial diagnostic facet joint injection or medial branch block.

Included careConservative care may include pharmacotherapy, exercise, or physical therapy.

Pain After Conservative Care

Required pain levelPain remains at 3 or more on a 1–10 pain scale after conservative care.

TimingThe pain threshold applies after a minimum of 4 weeks of conservative care.

Provider Documentation and Action Requirements

Step Therapy

Initial Conservative-Care Trial Required

Before requesting an initial diagnostic facet joint injection or medial branch block, document a minimum 4-week trial of conservative care and the patient’s response. The trial should be individualized and may include medication, exercise, physical therapy, spinal manipulation, cognitive behavioral therapy, or other appropriate measures.

Document persistent pain of at least 3/10 after the conservative-care trial.
Record the specific treatments attempted and the duration of each treatment.

Step Therapy

Lumbar Conservative Treatment Before Intervention

For lumbar facet interventions, document a 3-month trial of different conservative treatments before the procedure. Continue appropriate conservative measures alongside the intervention.

Potential measures include medications, exercise, heat or cold therapy, massage, acupuncture or spinal manipulation when indicated, nutrition, weight loss, and sleep hygiene.

Clinical Background

Facet joint injections place local anesthetic, with or without corticosteroid, into the facet joint capsule. Medial branch blocks target the nerves supplying the facet joints and may use local anesthetic, with or without corticosteroid. In this policy, these procedures are primarily used diagnostically to determine whether facetogenic pain may respond to radiofrequency denervation or ablation, rather than as ongoing therapeutic treatment for spinal pain.

Policy Definitions

Acute Low Back Pain

DefinitionLow back pain present for up to 6 weeks.

Early acute phaseLess than 2 weeks.

Late acute phase2 to 6 weeks.

Conservative Therapy

DefinitionAn appropriate combination of medication and additional individualized interventions.

Medication examplesNonsteroidal anti-inflammatory drugs and analgesics.

Other componentsPhysical therapy, spinal manipulation therapy, cognitive behavior therapy, or other interventions based on presentation, physical findings, and imaging.

Required Conservative Treatment Before Intervention

Pain and conservative care before initial diagnostic injection

Before an initial diagnostic injection, all of the following conservative-care requirements must be met.

Initial diagnostic injection conservative-care requirement

The patient has completed a minimum of 4 weeks of conservative care, consisting of an appropriate combination of medication and activity-based or rehabilitative treatment such as exercise or physical therapy.Minimum 4 weeks
Pain remains at 3 or more on a 1–10 pain scale after conservative care.Pain ≥3/10

Conservative treatment before lumbar facet intervention

Before lumbar facet interventions, complete the following conservative-treatment trial.

Injection Frequency and Repeat-Procedure Limits

Frequency Limit

Diagnostic limitAfter two facet joint injections or medial branch blocks at the same level and same side, additional injections are considered therapeutic rather than diagnostic.

Coverage statusAdditional therapeutic injections are unproven and not medically necessary.

Applies toFacet joint injections and medial branch blocks.

Image Guidance Requirements

Billing Rule

Use required image guidance

Use image guidance for facet joint injections and medial branch blocks. The applicable reference procedure codes specify fluoroscopy or CT image guidance; ultrasound-guided performance is excluded as unproven and not medically necessary.

Use fluoroscopy or CT for the applicable cervical, thoracic, lumbar, or sacral procedures.
Do not bill ultrasound-guided facet or medial branch procedures as covered services.

Documentation Required

Obtain CT or MRI before upper-cervical joint injection

Before atlanto-occipital or atlanto-axial joint injections, obtain advanced cervical spine imaging with CT or MRI to ascertain pathology and help guide needle trajectory.

Not-Covered Services

The following services are not covered: therapeutic facet joint injections; therapeutic medial branch blocks for chronic spinal pain; facet joint injections or medial branch blocks after diagnostic injections have been completed; ultrasound-guided facet joint injections or medial branch blocks; and medial branch blocks using more than 0.5 mL of local anesthetic.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain

Policy CodePolicy CSNCT0005.08

Change TypeAdministrative updateno material clinical or coverage change

Effective DateNovember 1, 2026

Next Review DateN/A

Key ActionBefore an initial diagnostic injection, complete at least 4 weeks of conservative care, with pain remaining at 3 or more on a 1–10 scale.

SourceLink

On This Page

Conservative measures continue during the prognostic-block treatment course.

Positive prognostic response

The prognostic block produces at least a 50% reduction in pain.≥50% pain reduction
Activity or other nonpain measures may supplement pain assessment but are not used as the sole criterion for determining success or failure.

Clinical contextClinically significant improvement must not have occurred.

Positive Diagnostic Block Response

Minimum reliefAt least 50% pain relief.

DurationRelief must last at least the expected minimum duration of the local anesthetic used.

Applies toDiagnostic facet joint injections and medial branch blocks.

Medial Branch Block Anesthetic Volume

Maximum volumeNot more than 0.5 mL of local anesthetic.

ProcedureMedial branch block.

Coverage limitationA block exceeding 0.5 mL is unproven and not medically necessary.

First-Block Response for Confirmatory Injection

Required reliefAt least 80% relief of the primary or index pain.

Onset and durationThe onset and minimum duration of relief must be consistent with the anesthetic used.

Next stepA confirmatory injection may then be performed at the same location.

Confirmatory Block Diagnostic Response

Diagnostic responseMore than 80% reduction of index pain confirms the tested joint as the pain source.

SequenceThe response is evaluated after the confirmatory block.

LocationDual blocks are performed at the same location on two separate occasions.

Single Diagnostic Intra-articular Injection

Relief threshold50% relief after a single diagnostic intra-articular injection.

Evidence contextThe threshold is discussed in NASS evidence recommendations.

Reported outcomeIntra-articular steroid injection provided no clinically meaningful improvement at 6 months in the cited evidence.

Step Therapy

Cervical Conservative Management Required

Before a cervical prognostic block, document neck pain present for at least 3 months, a personalized conservative-therapy trial of at least 6 weeks, and ongoing conservative measures used with the block.

Document the conservative treatments attempted and the patient’s response.
Do not rely on the block as a substitute for ongoing conservative management.

Documentation Required

Sequential Diagnostic Blocks

Use sequential diagnostic medial branch blocks to confirm the pain generator. Perform dual blocks at the same location on two separate occasions because a single diagnostic anesthetic injection has an unacceptably high false-positive rate.

A confirmatory block is indicated only when the first block produces at least 80% relief of the primary index pain and the onset and minimum duration are consistent with the anesthetic used.
The policy’s second injection must be at the same level and side as the initial block.
A different or additional level may be considered when pain is believed to arise from another joint and initial relief is below 80%, consistent with the guideline recommendation.

Documentation Required

Initial Diagnostic Injection Documentation

For the initial diagnostic injection, document facetogenic findings and rule out competing pain sources. The examination should show pain exacerbated by facet-loading maneuvers such as hyperextension or rotation, with pain remaining at 3/10 or greater after conservative care.

Document clinical findings and imaging showing no other cause, including stenosis with neurogenic claudication, disc herniation with radicular pain, infection, tumor, fracture, or pain related to prior surgery.
Confirm that the spinal motion segment is not fused.
Document that radiofrequency joint denervation or ablation is being considered.

Documentation Required

Confirmatory Injection Response

For a confirmatory injection, document that it is performed at the same spinal level and on the same side as the initial block. The initial block must have produced a positive response before the second injection is requested.

Record relief for at least the expected minimum duration of the local anesthetic’s effect.
Document functional improvement specific to the patient, including physical functions previously limited by facetogenic pain.
Confirm that radiofrequency denervation or ablation remains under consideration.

Documentation Required

Pain and Functional Outcome Documentation

Document both the magnitude and duration of pain relief after each diagnostic block, together with meaningful improvement in patient-specific function. A diagnostic facet injection or medial branch block is generally considered positive at least 50% pain relief for at least the expected duration of the local anesthetic; NASS guidance uses greater than 80% relief for confirmatory-block selection.

Record the pain score before and after the block and the percentage reduction.
Record onset and duration of relief and relate them to the anesthetic used.
Describe demonstrable functional gains rather than relying on pain relief alone.

Documentation Required

Cervical Presentation and Imaging Rationale

Select cervical block targets from the clinical presentation, including focal tenderness or pain-referral patterns, and document the rationale for the selected levels. History and physical examination alone may not reliably identify painful C0-C1 or C1-C2 joints.

Obtain preprocedural cervical CT or MRI before atlanto-occipital or atlanto-axial joint injections to identify pathology and guide needle trajectory.
Use fluoroscopy or ultrasound for cervical medial branch blocks.
Document cervical medial branch block volume of 0.3 mL or less; cervical interarticular facet injection volume should not exceed 1 mL including contrast.

Documentation Required

Diagnostic Block Response

For every diagnostic block, document the percentage reduction in the primary pain, the onset and duration of relief, and the patient’s functional response. The response must be interpreted against the expected duration of the anesthetic and the applicable confirmation threshold.

Guideline-based positive response: at least 50% pain reduction may support a prognostic block.
For NASS confirmatory-block selection: at least 80% relief of the index pain, with compatible onset and minimum duration.
Activity or other nonpain measures may supplement, but must not be the sole basis for determining success or failure.

Documentation Required

Conservative Treatment History

The record must identify the conservative treatments attempted, how long they were used, the response to each, and which measures remain ongoing before a lumbar or cervical diagnostic intervention.

Include medications, exercise or physical therapy, heat or cold therapy, massage, acupuncture or spinal manipulation when indicated, and other individualized measures.
For cervical blocks, document at least 6 weeks of conservative therapy within the context of at least 3 months of neck pain.
Document continued conservative measures during the prognostic-block plan.

Denial Risk

Initial Diagnostic Criteria Not Met

Do not request an initial diagnostic facet joint injection or medial branch block when the required initial criteria are not documented or are not met.

No documented facet-loading pain on examination.
Pain has improved to below 3/10 or the minimum 4-week conservative-care trial is absent.
Clinical findings or imaging suggest another pain source.
The motion segment is fused or radiofrequency denervation/ablation is not being considered.

Denial Risk

Confirmatory Injection Criteria Not Met

Do not request a second diagnostic injection when the confirmatory criteria are absent.

The injection is not planned at the same level and side as the initial block.
The initial block did not produce the required positive response, including adequate pain relief, expected anesthetic duration, and patient-specific functional improvement.
Radiofrequency denervation/ablation is not being considered at the requested level.

Denial Risk

Therapeutic or Non-Prognostic Use

Facet joint injections and medial branch blocks are not supported as therapeutic treatment after diagnostic injections are complete or when radiofrequency ablation is not being considered as a treatment option at the requested level.

After two injections at the same level and side, additional use is considered therapeutic rather than diagnostic.
Routine therapeutic facet joint or medial branch block treatment for chronic spinal pain is unproven and not medically necessary.

Denial Risk

Invalid Clinical Indication

Do not proceed when the initial diagnostic block failed to confirm the facet joint as the pain source or when untreated radiculopathy is present at the intended level.

Exception: radiculopathy caused by a facet joint synovial cyst.
Document confirmation of the facetogenic pain source before requesting a second diagnostic injection.

Denial Risk

Ultrasound Guidance Not Medically Necessary

Procedures performed under ultrasound guidance are unproven and not medically necessary under this policy. Use the policy-supported imaging guidance and document the guidance method.

The evidence does not demonstrate an overall health benefit over fluoroscopy or CT.
Evidence indicates a risk of incorrect needle placement with ultrasound-guided lumbar medial branch blocks and facet injections.

Billing Rule

Local-Anesthetic Volume Limit

For medial branch blocks, keep the total local-anesthetic volume at 0.5 mL or less. Volumes above this threshold create denial risk and may increase spread to adjacent structures.

Document the anesthetic volume in the procedure record.
For cervical medial branch blocks, document the more specific volume limit of 0.3 mL or less, except for limited guideline-described circumstances.

Denial Risk

Unsupported Therapeutic Indications

Do not use therapeutic facet injections as routine treatment for acute, subacute, radicular, or nonspecific chronic spinal pain.

ACOEM does not recommend treatment of acute or subacute low back pain or radicular pain syndromes.
Routine treatment of chronic, nonspecific axial pain is moderately not recommended.
Repeat intra-articular therapeutic injections are not recommended when prior injections did not produce lasting functional improvement.

Denial Risk

Routine Steroid Use Not Supported

Avoid routine steroid use with facet interventions. Therapeutic steroid injections and steroid-containing medial branch blocks are generally unsupported, with only limited guideline-described exceptions.

ASRA recommends against routine therapeutic facet injections but notes limited exceptions for patients at risk from radiofrequency ablation or with a strong likelihood of success.
Avoid routine steroids with cervical medial branch blocks; if an interarticular injection is considered in a limited exception, use nonparticulate steroid as described by the guideline.
VA/DoD suggests against corticosteroids for intra-articular facet injections and therapeutic medial branch blocks.

Denial Risk

Ultrasound Accuracy Uncertain

Do not assume ultrasound-guided accuracy is equivalent to fluoroscopy or CT. The evidence is limited and includes a material risk of incorrect needle placement.

Published evidence lacks demonstrated overall health benefit for ultrasound over fluoroscopy or CT.
Reported pooled risk differences for incorrect needle placement were 11% for ultrasound-guided medial branch blocks confirmed by fluoroscopy and 13% for ultrasound-guided facet injections confirmed by CT.
The certainty of evidence was low to very low because of bias, inconsistency, imprecision, and variation in clinician training.

Facet Joint Injections

DefinitionInjection of a local anesthetic and/or corticosteroid into the facet joint capsule.

Diagnostic useA diagnostic injection or medial branch block is used to evaluate facet joint pain.

Positive resultAt least 50% pain relief for at least the expected minimum duration of the local anesthetic.

Facet Joint Syndrome

DefinitionA condition causing chronic spinal pain of unclear etiology.

Typical pain patternCervical, thoracic, or low-back pain may radiate to the buttock and posterior thigh.

Typical findingsPain with hyperextension, joint tenderness, and absence of radiculopathy below the knee and neurological deficits.

Facet Nerve Block

DefinitionInjection of a local anesthetic and/or corticosteroid along the nerves supplying the facet joints.

Diagnostic responseA diagnostic medial branch block is positive with at least 50% pain relief.

Duration of responseRelief must last at least the expected minimum duration of the local anesthetic used.

Medial Branch Block

DefinitionA medial branch block is another term for a facet nerve block.

TargetThe nerves supplying the facet joints.

Diagnostic thresholdAt least 50% pain relief for at least the expected minimum duration of the local anesthetic.

Non-Radicular Back Pain

DefinitionPain that does not radiate along a dermatome.

Imaging characteristicAppropriate imaging does not show spinal nerve-root compression.

Clinical characteristicClinical examination does not show evidence of spinal nerve-root compression.

Radicular Back Pain

DefinitionPain radiating from the spine into an extremity along the course of an irritated spinal nerve root.

DistributionThe pain follows the dermatome associated with the irritated nerve root.

Anatomic patternRadiation extends from the spine into an extremity.

Radiculopathy

DefinitionSymptoms caused by spinal nerve-root irritation.

Pain patternPain radiates outward from the spine to areas away from the source.

SourceThe symptoms arise from irritation of a spinal nerve root.

Subacute Low Back Pain

DefinitionLow back pain lasting more than 6 weeks but no longer than 12 weeks after symptom onset.

Minimum durationMore than 6 weeks.

Maximum duration12 weeks or less.

Diagnostic Facet or Medial Branch Block

DefinitionAn injection or block used to determine whether a spinal facet joint or its medial branch nerve is the source of index pain.

Potential targetsA spinal facet joint or the medial branch nerve supplying it.

Clinical purposeTo identify the source of the patient's primary or index pain.

Positive Block

DefinitionA diagnostic block response defined by a specified percentage reduction in primary or index pain.

Reported thresholdsPolicy-cited thresholds range from greater than 50% to at least 80%.

Threshold depends onThe guideline and clinical purpose of the block.

Prognostic Block

DefinitionA block performed to predict response to medial branch radiofrequency ablation.

Predictive valueMedial branch blocks provide more predictive information than facet joint injections.

Related treatmentThe predicted treatment is medial branch radiofrequency ablation.

Dual Diagnostic Medial Branch Blocks

DefinitionTwo diagnostic medial branch blocks performed in the same location or locations on two separate occasions.

PurposeTo confirm the source of the patient's pain.

Reason for sequenceDual blocks address the high false-positive rate of a single diagnostic anesthetic injection.

Therapeutic Medial Branch Blocks

DefinitionMedial branch blocks performed with the intent of achieving long-term pain management.

IntentTherapeutic management rather than diagnostic confirmation.

Evidence statementCurrent evidence does not support their use as a therapeutic intervention.

Zygapophyseal Joint

Anatomic termZygapophyseal joint.

Common nameFacet joint of the spine.

Clinical contextThe term is used in evidence discussing facet-mediated pain and facet procedures.

Lumbar conservative-treatment trial

The patient completes a 3-month trial of different conservative treatments before lumbar facet intervention.3 months
Treatment may include medications, exercise, heat or cold therapy, massage, acupuncture or spinal manipulation when indicated, nutrition, weight loss, and sleep hygiene.

Conservative management before cervical prognostic blocks

Before cervical prognostic blocks, apply all of the following requirements.

Cervical prognostic-block conservative management

The patient has at least 3 months of neck pain.At least 3 months of neck pain
The patient completes at least 6 weeks of conservative therapy before the prognostic block.At least 6 weeks of conservative therapy
Conservative measures continue concomitantly with the prognostic blocks.

Document the preprocedural CT or MRI findings.
Use the imaging to support target selection and needle trajectory.

Billing Rule

Use image guidance for cervical medial branch blocks

Use fluoroscopy or ultrasound for cervical medial branch blocks, as described in the source guidance. Document the imaging guidance used and the targeted cervical levels.

For cervical medial branch blocks, use fluoroscopy or ultrasound.
Cervical medial branch block volumes are described as ≤0.3 mL, with limited allowance for higher volume when contrast spread does not capture common innervation patterns.