ModifiedColorado Rocky Mountain Health PlansPolicy 2026T0004VV

Facet Joint and Medial Branch Block Injections for Spinal Pain

Clinical coverage criteria, definitions, and coding guidance for diagnostic and therapeutic facet joint and medial branch (medial branch block) injections for spinal pain for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain

Policy CodePolicy 2026T0004VV

Change TypeUpdated clinical evidence, description of services, and references

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument conservative therapy trials and diagnostic block results (percent pain relief, timing, technique) in prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

50%positive diagnostic block threshold

≥4 weeksmin conservative care before initial block

0.5 mLmax anesthetic volume (medial branch)

≤2diagnostic injection limit

05/01/2026

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latest policy revision

Coverage Criteria for Facet Joint and Medial Branch Injections

Initial diagnostic facet joint/medial branch injection

Covered when ALL of the following are met

Initial diagnostic block criteria: Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation); clinically significant improvement has not occurred (pain remains ≥3/10) after a minimum of 4 weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy); clinical findings and imaging studies suggest no other cause of the pain (e.g., spinal stenosis with neurogenic claudication, disc herniation with radicular pain, infection, tumor, fracture, pain related to prior surgery); the spinal motion segment is not fused; and a radiofrequency joint denervation/ablation procedure is being considered.

Second confirmatory diagnostic block

Covered when ALL of the following are met

Second confirmatory block criteria: Administered at the same level and side as the initial block; the initial diagnostic Facet Joint Injection produced a positive response for at least the expected minimum duration of the effect of the local anesthetic; functional improvement specific to the individual with demonstrable improvement in the physical functions previously limited by the facetogenic pain; and a radiofrequency joint denervation/ablation procedure is being considered.

Coverage with criteria — diagnostic and selective therapeutic use

Covered when ALL of the following are met

General coverage criteria

Conservative therapy requirement: Trial of conservative treatments prior to interventions: e.g., for lumbar pain a 3-month trial; for cervical pain at least a 6-week trial (individualization allowed).
Diagnostic block confirmation: Use of diagnostic medial branch blocks with concordant pain relief; dual blocks (two separate occasions) with >= 80% relief are generally required to confirm lumbar facet-mediated pain per guideline guidance; single blocks have high false-positive rates.>= 80% relief for confirmatory dual blocks
Procedure technical parameters: Use recommended injectate volumes to limit spread (lumbar MBB <0.5 mL total, lumbar interarticular <1.5 mL; cervical MBB <=0.3 mL, cervical interarticular <=1 mL) and apply appropriate imaging guidance (fluoroscopy/CT; ultrasound guidance is not accepted for coverage in many cases).

Diagnostic Medial Branch Block Criteria

Covered when ALL of the following are met:

Dual diagnostic blocks: Dual medial branch blocks performed in the same location(s) on two separate occasions are necessary to confirm facet-mediated spinal pain due to the unacceptably high false-positive rate of single diagnostic anesthetic injections.

From guideline recommendations; second block indicated only after ≥80% relief from first and relief duration consistent with agent used.

Alternative levels: A second injection may be performed at a different or additional level if initial block provided < 80% relief and pain is believed to arise from a different joint.

From guideline recommendations.

Therapeutic Medial Branch and Intra-articular Injection Stance

Therapeutic medial branch blocks and intra-articular injections:

Evidence insufficient for routine therapeutic use: Current evidence does not support therapeutic medial branch blocks as an effective long-term treatment; professional guidance states insufficient evidence to recommend for or against many therapeutic injections, and intra-articular steroid injections show no clinically meaningful improvement at 6 months in selected studies.

Recommendations and evidence summaries from NASS and recent systematic reviews.

Requests for facet joint or medial branch injections are considered unproven and not medically necessary when a radiofrequency ablation/denervation procedure is not being considered at the requested level(s). The policy also identifies several specific denial conditions: injections performed after two blocks at the same level/side (which are considered therapeutic rather than diagnostic); therapeutic injections intended for chronic spinal pain; a second diagnostic injection if the initial injection was negative; procedures performed under ultrasound guidance; and medial branch blocks in which the injected local anesthetic volume exceeds 0.5 mL. Therapeutic facet joint/medial branch block injections at cervical, thoracic, and lumbar levels are described as unproven due to insufficient evidence of efficacy and safety.

Multiple specialty guidance documents caution against routine therapeutic intra-articular facet injections and routine use of corticosteroids with medial branch blocks. The ASRA guidance recommends against routine therapeutic facet injections while allowing selective use of steroids in specific patients at higher procedural risk or with prior substantial diagnostic response. The VA/DoD 2022 guideline similarly suggests against corticosteroid use for intra-articular facet injections and therapeutic medial branch blocks because of limited and inconsistent evidence of benefit.

The NASS review found no published literature addressing intra-articular facet joint injections specifically for thoracic pain. Given the limited evidence for thoracic facet procedures and the predominance of retrospective series, clinicians are advised to carefully weigh the risks and benefits and to consider conservative or palliative alternatives when managing thoracic spine pain.

Therapeutic facet joint injections and therapeutic medial branch (facet nerve) blocks intended for long-term pain control are considered unproven and not medically necessary at cervical, thoracic, and lumbar levels because current evidence does not support durable clinical benefit. NASS and other guideline reviews note low to very low quality evidence and recommend against routine therapeutic use; when diagnostic confirmation is required, procedural selection should follow those diagnostic thresholds rather than be used as standalone therapeutic interventions.

Systematic reviews and guideline assessments demonstrate that intra-articular facet joint steroid injections have heterogeneous and generally low-quality evidence for sustained benefit. A 2025 systematic review of fluoroscopically guided lumbar intra-articular steroid injections found wide variability in pain relief (13%–74%) and downgraded the body of evidence to very low quality due to bias, inconsistency, and imprecision. For these reasons, routine therapeutic intra-articular injections are not supported as a standard long-term treatment.

Therapeutic medial branch blocks (performed with anesthetic ± steroid to produce long-term pain control) lack convincing evidence of long-term efficacy and are therefore not considered a supported routine therapeutic option. NASS and other guideline sources state there is insufficient evidence to recommend therapeutic medial branch blocks or routine intra-articular steroid use for durable improvement; when used, these interventions should be reserved for select circumstances and documented thoroughly.

Coding and Diagnostic Thresholds

Ultrasound-guided facet injection codesCPT

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 (List separately in addition to code for primary procedure).
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) (List separately in addition to code for primary procedure).
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 (List separately in addition to code for primary procedure).
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) (List separately in addition to code for primary procedure).

Fluoroscopy/CT-guided facet 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 (List separately in addition to code for primary procedure).
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) (List separately in addition to code for primary procedure).

Applicable diagnosis codes (examples listed)ICD-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.

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inv-15: Positive diagnostic block — ≥ 50% pain relief

Positive diagnostic blockAt least 50% pain relief for at least the expected minimum duration of the local anesthetic effect

ContextUsed to determine facet joint origin when combined with clinical findings and imaging

MeasurementPain reduction assessed on a 1–10 scale (50% corresponds to clinically meaningful improvement)

inv-16: Conservative care duration — Minimum of 4 weeks

Minimum durationMinimum of 4 weeks of conservative care prior to initial diagnostic injection

Pain level requirement

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization: Conservative therapy and diagnostic confirmation — Prior authorization for diagnostic facet joint/medial branch block injections should document an adequate trial of conservative therapy and the plan for diagnostic confirmation. Conservative therapy documentation should reflect individualized trials (e.g., lumbar: approximately 3 months of conservative care; cervical: at least 6 weeks in many recommendations) including pharmacologic management, physical therapy/exercise, and other integrative or noninvasive measures. Prior authorization should also include the intended diagnostic strategy (single vs dual/confirmatory block), criteria for a positive response (percent pain relief and duration consistent with the local anesthetic used), and whether radiofrequency joint denervation/ablation is being considered as the next therapeutic step.

Document conservative therapy trials (type, duration, response)
Record diagnostic block strategy: single vs dual (confirmatory) blocks planned
Record percent pain relief and timing relative to agent used (e.g., onset and duration)
State whether radiofrequency joint denervation/ablation is being considered

Note

Conservative Treatment Requirements Before Diagnostic Procedures

Required prior to initial diagnostic injection — ≥ 4 weeks

Required prior to initial diagnostic injection: Minimum of 4 weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy) with pain remaining at least 3/10.

Trial of conservative therapy prior to diagnostic/prognostic blocks — Lumbar: 3 months; Cervical: at least 6 weeks (individualize)

Trial of conservative therapy prior to diagnostic/prognostic blocks: Lumbar: a 3-month trial of conservative therapies (e.g., medications, physical treatments, integrative treatments); Cervical: at least a 6-week trial of conservative therapy (may be individualized) with concomitant conservative measures encouraged.

Frequency Limits for Diagnostic and Therapeutic Injections

inv-48: Facet joint/medial branch block — Frequency limit

Diagnostic injection limitNo more than two diagnostic injections at the same level and side for diagnostic purposes

More than two considered>2 injections at same level/side are considered therapeutic and unproven/not medically necessary

Denial riskRequests for injections after two blocks at same level/side may be denied

inv-49: Diagnostic medial branch blocks; therapeutic intra-articular injections

Dual diagnostic approachDual diagnostic medial branch blocks should be performed on two separate occasions to confirm diagnosis

Therapeutic injection repeat stanceRepeat therapeutic intra-articular injections are generally not recommended for routine repeated use

Imaging and Guidance Requirements

Billing Rule

Use fluoroscopy or CT guidance; ultrasound-only guidance not accepted

Fluoroscopy or CT guidance is preferred for facet joint/medial branch injections; procedures performed solely under ultrasound guidance are listed as unproven and not medically necessary.

Ultrasound-guided CPT codes are listed but the policy states injections under ultrasound guidance are unproven/not medically necessary.
Use image guidance (fluoroscopy or CT) per coding and imaging requirements.

Billing Rule

High-cervical injections: obtain CT/MRI; use fluoroscopy/US for cervical MBB

For atlanto‑occipital and atlanto‑axial (high cervical) injections, obtain preprocedural CT or MRI to guide needle trajectory; for cervical medial branch blocks, fluoroscopy or ultrasound is recommended and cervical volumes have specified limits.

Preprocedural CT/MRI recommended prior to atlanto‑occipital and atlanto‑axial injections.

Services Not Covered / Considered Not Medically Necessary

The policy identifies multiple scenarios that are not covered because they are unproven or lack sufficient evidence: therapeutic facet joint/medial branch block injections at cervical, thoracic, and lumbar levels; injections performed after two diagnostic blocks at the same level/side; a second diagnostic injection when the initial injection was negative; medial branch blocks with local anesthetic volume exceeding 0.5 mL; injections performed under ultrasound guidance; and injections performed when radiofrequency ablation is not being considered at the requested levels. Requests in these categories may be denied.

More than two facet joint or medial branch injections at the same level and side are considered therapeutic rather than diagnostic and are not covered. The ASRA and other reviews recommend against routine therapeutic repeat injections, and guideline-based frequency limits restrict diagnostic injections to a maximum of two per level/side for diagnostic confirmation.

Medial branch blocks performed with a total local anesthetic volume greater than 0.5 mL are listed as unproven and may be denied; the policy emphasizes using small injectate volumes to limit spread and preserve diagnostic specificity. Similarly, procedures performed under ultrasound guidance are identified as unproven and not covered by this policy.

A second diagnostic injection is considered not covered when the initial diagnostic block did not confirm the joint as the pain source. The policy limits diagnostic injections to procedures that contribute to diagnostic certainty for subsequent radiofrequency denervation; repeating blocks after a negative initial block is not supported.

Therapeutic intra-articular facet joint injections and routine use of steroids with medial branch blocks are described as not covered or not recommended by multiple guideline sources. Reviews note low-quality evidence, variable response rates, and lack of demonstration of clinically meaningful improvement at longer follow-up intervals, leading to a stance against routine therapeutic use.

Definitions

inv-38: Facet Joint Injections — definition and diagnostic positivity

DefinitionFacet Joint Injections: Injection of local anesthetic and/or corticosteroid into the facet joint capsule

Diagnostic positivityConsidered positive when ≥50% relief for at least the expected duration of the local anesthetic

RoleUsed to diagnose facetogenic spinal pain though medial branch blocks are generally more appropriate diagnostically

inv-39: Medial Branch Block / Facet Nerve Block — definition

DefinitionMedial Branch Block/Facet Nerve Block: Injection of local anesthetic and/or corticosteroid along the nerves supplying facet joints

Diagnostic criterionDiagnostic block positive when ≥50% relief for at least the expected duration of the anesthetic

Background

Facet joint and medial branch injections are commonly used as diagnostic tools to determine a facetogenic source of spinal pain by injecting local anesthetic, with or without corticosteroid, into the facet joint or around the medial branch nerve that innervates it. Diagnostic blocks are considered positive when they produce ≥ 50% pain relief for at least the expected minimum duration of the local anesthetic effect, and single blocks have a high false-positive rate; this underlies recommendations for dual confirmatory blocks in many guideline statements.

Revision History

2026-05-01policy_revisionLatest

Policy updated: Description of Services, Clinical Evidence, and References sections revised; previous policy version 2026T0004UU archived.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyFacet Joint and Medial Branch Block Injections for Spinal Pain

Policy CodePolicy 2026T0004VV

Change TypeUpdated clinical evidence, description of services, and references

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument conservative therapy trials and diagnostic block results (percent pain relief, timing, technique) in prior authorization requests.

SourceLink

On This Page

Pain remains at least 3/10 despite conservative care

Conservative care examplesIncludes pharmacotherapy, exercise, or physical therapy (individualized)

inv-17: Diagnostic relief threshold (lumbar) — >= 80% for dual blocks

Lumbar confirmatory threshold>= 80% pain relief on dual medial branch blocks to confirm lumbar facet-mediated pain

OccasionsDual blocks must be performed on two separate occasions

When second block allowedSecond confirmatory injection indicated only if first produced ≥80% relief with timing consistent with anesthetic used

inv-18: Cervical medial branch block volume — <= 0.3 mL total

Maximum total volume (cervical MBB)≤ 0.3 mL total injectate for cervical medial branch blocks

RationaleLimit spread to adjacent structures and preserve diagnostic specificity

AllowanceSlightly higher volumes may be considered if contrast spread does not capture expected medial branch patterns

inv-19: Lumbar medial branch block volume — < 0.5 mL total

Maximum total volume (lumbar MBB)< 0.5 mL total for lumbar medial branch blocks

Denial conditionMedial branch blocks with local anesthetic volume > 0.5 mL are considered unproven and may be denied

PurposeReduced injectate volume minimizes spread to adjacent structures improving diagnostic accuracy

inv-20: Cervical interarticular injection volume — <= 1 mL total (including contrast)

Maximum total volume (cervical intra-articular)≤ 1 mL total (including contrast) for cervical interarticular facet joint injections

RationalePrevent capsular rupture and limit aberrant injectate spread to enhance specificity

Imaging notePreprocedural CT or MRI recommended for atlanto-occipital/atlanto-axial injections to guide needle trajectory

inv-21: Lumbar interarticular injection volume — < 1.5 mL total

Maximum total volume (lumbar intra-articular)< 1.5 mL total for lumbar interarticular facet joint injections

RationaleLimits capsular rupture and spread to adjacent structures

EvidenceASRA guidance recommends this volume to prevent capsular rupture

inv-22: Conservative therapy trial duration (lumbar) — 3 months

Lumbar trial duration3 months of conservative therapy before lumbar facet interventions

Therapies includedMedications, physical treatments (exercise, heat/cold), integrative treatments (acupuncture), and other individualized measures

DocumentationPrior authorization and records should reflect the documented conservative trial

inv-23: Conservative therapy trial duration (cervical) — At least 6 weeks

Cervical trial durationAt least 6 weeks of conservative therapy before cervical prognostic blocks (individualize per patient)

IndividualizationDuration may vary based on personalized care; concomitant conservative measures are recommended

Preprocedural imagingCT or MRI recommended prior to atlanto-occipital/atlanto-axial injections

inv-24: Confirmatory pain relief threshold — >= 80%

Confirmatory threshold>= 80% pain relief on confirmatory block to confirm facet joint as pain source

Timing requirementOnset and minimum duration of relief must be consistent with the anesthetic agent used

UseApplied when performing dual diagnostic medial branch blocks to establish diagnostic certainty

Check Benefit Plan for Authorization

Check member-specific benefit plan for authorization requirements and applicable mandates — Coverage and prior authorization requirements vary by product and contract. Confirm member eligibility, benefit limits, site-of-service rules, and any applicable federal/state mandates or prior authorization programs before scheduling services.

Verify member-specific prior authorization requirements
Confirm site-of-service and benefit limits (commercial vs exchange)
Follow applicable federal/state mandates

Documentation Required

Medical Records Needed for Review

Medical records may be required for review — Medical records documentation may be requested to determine whether clinical criteria for coverage are met. Submission of records supports adjudication but does not guarantee coverage if the member’s benefit plan excludes the service.

Provide complete medical records relevant to the pain complaint
Include prior conservative therapy notes, imaging, and procedural reports
Attach prior authorization rationale and any prior procedure outcomes

Documentation Required

Required Clinical Documentation

Required documentation elements — To support medical necessity and prior authorization, include documentation of: pain history and severity, physical exam findings (e.g., pain provoked by facet-loading maneuvers), relevant imaging excluding other causes, conservative therapy details and response, planned injection levels and laterality, agent(s) and volumes to be used, expected onset/duration of analgesia, percent pain relief from diagnostic block(s), and functional improvement measures when applicable. Specify whether fluoroscopic guidance will be used and record that volumes for medial branch blocks and intra‑articular injections follow guideline recommendations (e.g., lumbar medial branch blocks < 0.5 mL total; lumbar intra-articular < 1.5 mL; cervical medial branch ≤ 0.3 mL; cervical intra-articular ≤ 1 mL).

Pain severity (numeric rating) and index pain description
Physical exam provocation (facet loading maneuvers)
Relevant imaging and exclusion of alternative pain generators
Conservative therapy types, duration, and response
Planned levels/side, agent(s), and volumes with expected onset/duration
Percent pain relief and timing after diagnostic block(s)
Documentation of functional improvement and consideration of radiofrequency ablation

Step Therapy

Step Toward Radiofrequency Ablation

Step toward radiofrequency ablation — Diagnostic medial branch/facet joint blocks are considered proven and medically necessary when they are being used to confirm a target in patients for whom radiofrequency joint denervation/ablation is being considered. Clearly document that ablation is the contemplated next therapeutic option and that diagnostic blocks are intended to prognosticate response to denervation.

State that radiofrequency denervation/ablation is being considered
Tie diagnostic block results to candidacy for ablation (e.g., ≥80% relief for confirmatory lumbar blocks)

Note

Conservative-First Expectation

Conservative treatment context — Given limited evidence for therapeutic benefit from facet injections, conservative and alternative palliative treatments should be considered and documented prior to diagnostic procedures. Conservative-first expectation includes pharmacotherapy optimization, physical rehabilitation/exercise, integrative therapies (e.g., acupuncture, spinal manipulation when appropriate), weight management, and activity modification tailored to the patient.

Document conservative-first approach and concurrent use of conservative measures
Explain why conservative measures have been insufficient for the individual patient

Documentation needsRecord percent pain relief, timing relative to agent used, levels injected, and procedural technique for prior authorization

inv-50: Diagnostic medial branch blocks (dual injections at same location on separate occasions)

Dual injections definitionDual diagnostic medial branch blocks are two injections at the same targeted location(s) on separate occasions to confirm facet pain due to high false-positive rate of single blocks

Confirmatory conditionSecond injection indicated only after first produced ≥80% relief consistent with anesthetic duration

Alternative level useSecond injection may be at a different level if initial relief was <80% and pain source suspected elsewhere

Fluoroscopy or ultrasound should be used for cervical medial branch blocks; cervical MBB volume ≤0.3 mL and cervical interarticular ≤1 mL total.

Documentation Required

Document use of imaging guidance during injections

Imaging guidance (e.g., fluoroscopy or ultrasound) is generally expected for facet joint and medial branch block injections and should be documented in the record.

Document the imaging modality used during the procedure in clinical records and authorization materials.

Routine therapeutic medial branch blocks and intra-articular steroid injections for long-term pain control are not supported by current guidelines and evidence summaries, including NASS and VA/DoD guidance. These interventions are therefore generally not covered as standard therapy and should be limited to exceptional circumstances with clear documentation of rationale and expected benefit.

ASRA guidance and other assessments explicitly recommend against routine therapeutic facet injections, while acknowledging limited exceptions (for example, patients at high risk from radiofrequency ablation or those with prior prolonged benefit from diagnostic injections). The policy aligns with these recommendations and classifies routine therapeutic intra-articular injections and routine steroid use with medial branch blocks as not covered in most cases.

Where evidence does not demonstrate clinically meaningful long-term improvement, routine therapeutic medial branch blocks and intra-articular steroid injections are considered not covered. Professional societies note the insufficiency of evidence to recommend these procedures for durable pain control; documentation of diagnostic confirmation and conservative therapy trials is expected if such interventions are requested.

UseGenerally considered more appropriate than intra-articular injections for diagnosing facet joint pain

inv-40: Conservative Therapy — definition

DefinitionConservative Therapy: Combination of medication and nonpharmacologic interventions (e.g., physical therapy, spinal manipulation, CBT) tailored to the individual

ExamplesNSAIDs, antidepressants, exercise, heat/cold, massage, acupuncture, weight loss, sleep hygiene

Role before proceduresRequired trial durations (e.g., ≥4 weeks or longer) before diagnostic/prognostic injections per policy and guidelines

inv-41: Diagnostic facet/medial branch block — definition

DefinitionDiagnostic facet/medial branch block: Injection of local anesthetic to the facet joint or medial branch nerve to determine whether the facet joint is the pain generator

ValidityDiagnostic validity has moderate support but single blocks have high false-positive rates

Use caseSelects patients for radiofrequency denervation when positive and other criteria met

inv-42: Therapeutic intra-articular steroid injection (IASI) — definition

DefinitionTherapeutic intra-articular steroid injection (IASI): Injection of steroid into the facet joint intended to provide pain relief and functional improvement

Evidence summarySystematic reviews show heterogeneous results with overall low to very low quality evidence and uncertain durable benefit

Routine use stanceRoutine therapeutic intra-articular injections are not generally recommended due to limited evidence

inv-43: Dual diagnostic medial branch blocks — definition

DefinitionDual diagnostic medial branch blocks: Two separate anesthetic injections at the same targeted location(s) on separate occasions to confirm facet joint pain

ReasonUsed because of high false-positive rate of single diagnostic injections

Confirmatory thresholdSecond injection only if first produced ≥80% relief consistent with anesthetic duration

inv-44: Confirmatory block threshold — >= 80% for second injection

Threshold for second blockA second confirmatory injection is indicated only if the first produced ≥80% relief of the index pain and the onset/duration matches the anesthetic used

PurposeEnsures specificity of diagnosis prior to proceeding to radiofrequency denervation

Alternative useIf first block <80% relief, a second block may be targeted to a different level if clinically suspected