CurrentevicorePolicy CMM-201

Facet Joint Injections/Medial Branch Blocks

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This policy governs medical necessity criteria, procedural limits, and imaging/agent requirements for facet joint injections and medial branch nerve blocks (C2-3 to L5-S1) for Cigna health plans administered by eviCore.

Policy Summary

Payerevicore

PolicyFacet Joint Injections/Medial Branch Blocks

Policy CodePolicy CMM-201

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionSubmit prior authorization with documentation showing >=80% pain relief from diagnostic blocks and required conservative therapy and imaging as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentevicorePolicy CMM-201

Facet Joint Injections/Medial Branch Blocks

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Policy Summary

Payerevicore

PolicyFacet Joint Injections/Medial Branch Blocks

Policy CodePolicy CMM-201

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionSubmit prior authorization with documentation showing >=80% pain relief from diagnostic blocks and required conservative therapy and imaging as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

C2-3 to L5-S1spinal levels covered

2max diagnostic injections per level

3max levels per session

>=80%diagnostic response threshold

3 monthsmin pain duration

Coverage Criteria — Facet Joint Injections & Medial Branch Blocks

Coverage criteria (summary)

Covered when ALL of the following are met

Indication: Procedure is for facet-mediated pain and meets guideline criteria

Application limited to facet-mediated pain; see CMM-203 for sacroiliac joint procedures

Injectates: Performed with an anesthetic, corticosteroid, and/or contrast agent when criteria met

Image guidance: Performed with CT- or fluoroscopic-guidance when criteria met

Diagnostic injection frequency: Only two diagnostic injections/blocks at the same level(s) are considered medically necessary; a second diagnostic injection is required to confirm a positive response before considering radiofrequency ablation<=2 diagnostic injections per level

More than two at same level considered therapeutic

Levels and number per session: Performed only from spinal levels C2-3 to L5-S1 and on no more than three (3) facet joint levels (contiguous) per session<=3 levels per session

Exception allowed for facet injection at a level contiguous with a posteriorly fused segment

Session limit: Only one invasive modality/procedure is medically necessary on the same date of service1 invasive modality per date

Exception: facet injection performed with synovial cyst aspiration together with TFESI is allowed

Initial Diagnostic Criteria

Initial Diagnostic Facet Joint Injection/Medial Branch Nerve Block — Covered when ALL of the following are met

Purpose: Performed to determine whether chronic cervical, thoracic, or lumbar pain is of facet joint origin

Pain distribution: Presence of predominantly axial cervical, thoracic, or lumbar pain

Duration: Pain has persisted for at least three (3) months>= 3 months

Conservative therapy: Pain has persisted despite at least four (4) weeks of conservative treatment within the past three (3) months (e.g., exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics); if conservative treatment is contraindicated, the contraindication must be documented>= 4 weeks conservative

Second Diagnostic Criteria

Second Diagnostic Facet Joint Injection/Medial Branch Nerve Block — Covered when ALL of the following are met

Purpose: Performed to confirm the validity of the clinical response to the initial facet joint injection

Second diagnostic injection should be performed only with intent to proceed to RFA if confirmed

Level: Administered at the same level(s) as the initial diagnostic blocksame levels

Initial response: Initial diagnostic block resulted in a positive response (at least 80% relief of facet‑mediated pain for at least the expected minimum duration of the local anesthetic used)>=80% relief

Next step considered:

Therapeutic/Alternative to RFA Criteria

Therapeutic Facet Joint Injection/Medial Branch Nerve Block — Alternative treatment when RFA/neurotomy is contraindicated

RFA contraindication: Individual is not a candidate for RFA/neurotomy due to ONE of: established spinal pseudoarthrosis at intended level OR implanted electrical device (e.g., pacemaker, defibrillator, spinal/DRG stimulator, implantable drug pump)

Documented contraindication required

Initial alternative: Documented positive response to two (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s)>=80% relief x2

Positive response defined as >=80% relief for expected anesthetic duration

Subsequent therapeutic injections used as an alternative to RFA are medically necessary only when performed at least six (6) months after the prior therapeutic injection at the same level(s) AND prior documented pain relief was at least 50% for at least 12 weeks following the previous injection>=6 months interval AND >=50% relief for >=12 weeks

Synovial Cyst Aspiration Initial Criteria

Facet Joint Injection Performed with Synovial Cyst Aspiration — Covered when ALL of the following are met

Imaging confirmation: Advanced diagnostic imaging (e.g., MRI, CT, CT myelogram) confirms compression or displacement of the corresponding nerve root by a facet joint synovial cyst

Repeat Synovial Cyst Aspiration Criteria

Repeat Synovial Cyst Aspiration — Covered when

Response to prior aspiration: Documented pain relief of at least 50% for at least 12 weeks following the previous facet joint injection/medial branch nerve block>=50% relief for >=12 weeks

Facet joint injections and medial branch nerve blocks are considered medically necessary only for spinal levels from C2-3 to L5-S1. Additionally, when criteria are met these procedures are limited to no more than three (3) facet joint levels (unilateral or bilateral) during the same session; the policy further specifies these should be contiguous levels. An exception is allowed when a requested level is contiguous with a posteriorly fused spinal motion segment and the injection is performed at an unfused contiguous level.

Allowed injectates for facet joint injections/medial branch nerve blocks are limited to anesthetic, corticosteroid, and/or contrast agent administered alone or in combination when criteria have been met. Use of other injectates is considered not medically necessary.

The L5-S1 facet joint must not be used for diagnosis or treatment of sacroiliac (SI) joint–mediated pain; facet injections/medial branch nerve blocks of L5-S1 for SI joint indications are considered not medically necessary.

If an initial diagnostic block produces a positive response (defined elsewhere as ≥80% relief), a second diagnostic injection at the same level is required to confirm the response prior to proceeding to radiofrequency denervation. Additional diagnostic injections beyond two at the same level are not considered medically necessary, and prior successful radiofrequency denervation at the requested level(s) also precludes further diagnostic blocks.

Scheduling multiple facet joint injections/medial branch nerve blocks at the same level(s) as part of a series to be performed on a single date of service is not considered medically necessary; when criteria are met only one invasive modality or procedure on the same date is considered medically necessary (with specific exceptions noted elsewhere).

The referenced code listings in the document enumerate CPT/HCPCS procedure codes for facet joint injections and medial branch blocks (image-guided and related codes) but do not by themselves state additional explicit coverage exclusions beyond those specified in the policy text.

More than two diagnostic facet joint injections/medial branch nerve blocks performed at the same level and same side are considered therapeutic rather than diagnostic; such procedures must meet the therapeutic injection criteria rather than be treated as additional diagnostic blocks.

Procedures performed without meeting the Definitions, General Guidelines, and Indications sections of the policy are considered not medically necessary and may be denied.

Facet joint injections and medial branch nerve blocks performed with ultrasound guidance are identified in the document as experimental, investigational, or unproven and therefore are not covered under the policy.

When radiofrequency ablation/neurotomy is contraindicated, therapeutic injections can be considered as an alternative provided there has been documented positive response to two sequential diagnostic injections (each ≥80% relief). Subsequent therapeutic injections at the same level are medically necessary only when performed ≥6 months after the prior therapeutic injection and when the prior injection produced ≥50% pain relief for at least 12 weeks.

The referenced chunks for this section do not list additional specific conditions labeled explicitly as 'not medically necessary' beyond those already described in the policy (e.g., procedures lacking required documentation, exceeding diagnostic limits, use of disallowed injectates, L5-S1 for SI joint indications, or ultrasound-guided procedures).

Coding — Procedure Codes and Thresholds

CPT/HCPCS guidancemixed

No codes listed

Facet injection codes (fluoroscopy/CT guidance)CPT

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

Facet injection codes (ultrasound guidance)CPT

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.

Facet injection CPT codes (fluoroscopy/CT guidance)CPT

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

Facet injection CPT/HCPCS codes (ultrasound guidance - T codes)CPT

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).

inv-23: Positive response threshold

Positive response threshold>= 80% pain relief for the duration of the local anesthetic used

Documentation requirementResponse to the first two injections must be documented

Duration criterionRelief must persist for at least the expected minimum duration of the local anesthetic effect

inv-24: Pain relief thresholds

Diagnostic block threshold>= 80% pain relief to qualify as a positive diagnostic response

Repeat/therapeutic threshold

Provider Actions — Prior Authorization, Documentation & Denial Risks

Prior Authorization

Prior authorization requirement — case‑by‑case medical necessity review

Requests for facet joint injections/medial branch nerve blocks are evaluated for medical necessity on a case‑by‑case basis and must meet the guideline criteria, including level limits, frequency limits, and indication for facet‑mediated pain.

Appeals or authorizations should reference clinical documentation demonstrating criteria are met (see Required Clinical Documentation).

Billing Rule

Codes listed — verify plan prior authorization requirements

Codes for paravertebral facet injections/medial branch blocks are listed in the policy (image‑guided and ultrasound T‑codes); inclusion in the code table does not itself determine prior authorization — verify plan‑specific prior authorization rules.

Definitions

inv-39: Positive Response (diagnostic block)

DefinitionAt least 80% relief of facet-mediated pain for at least the expected minimum duration of the effect of the local anesthetic used

DocumentationResponse to the first two injections must be documented

PurposeUsed to identify facet-mediated pain prior to consideration of RFA

inv-40: Facet joint injection / Medial Branch Nerve Block (MBB)

ProcedureInjection of local anesthetic and possibly corticosteroid into the facet joint capsule or along the medial branch nerves supplying the facet joints (C2-C3 to L5-S1)

Diagnostic vs TherapeuticBoth can be used to diagnose facet joint pain, but medial branch block (MBB) is generally more appropriate for diagnosis

Background

Facet (zygapophyseal) joints are paired synovial joints innervated by medial branch nerves and can be a source of axial (non‑radicular) spinal pain. Diagnostic facet joint injections or medial branch nerve blocks use local anesthetic, often with corticosteroid, to identify facet‑mediated pain; a positive diagnostic response is defined as at least 80% pain relief for at least the expected duration of the anesthetic. These procedures are performed with image guidance (fluoroscopy or CT) at specified paravertebral facet levels to both diagnose and, when indicated, deliver therapeutic agents.

Policy Summary

Payerevicore

PolicyFacet Joint Injections/Medial Branch Blocks

Policy CodePolicy CMM-201

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionSubmit prior authorization with documentation showing >=80% pain relief from diagnostic blocks and required conservative therapy and imaging as applicable.

SourceLink

On This Page

Document contraindication if applicable

Exclude other causes: Clinical findings and imaging studies suggest no other obvious cause of axial pain (e.g., central spinal stenosis, foraminal stenosis or disc herniation with concordant radicular pain that has been treated, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation)

Surgical status: Spinal motion segment(s) are not posteriorly fused at the requested level(s)

Next step considered: A facet joint radiofrequency denervation/ablation is being considered

A facet joint radiofrequency denervation/ablation is being considered

For repeat therapeutic injections or repeat synovial cyst aspiration: >= 50% pain relief

Minimum duration for repeat/therapeutic response>= 12 weeks of documented relief to support subsequent therapeutic procedures

Fluoroscopy/CT CPT codes included: 64490, +64491, +64492, 64493, +64494, +64495.
Ultrasound T‑codes included: 0213T, +0214T, +0215T, 0216T (and additional T‑level codes in coding table).

Billing Rule

Affected procedure codes — use listed CPT/HCPCS codes for auth/claims

Procedure codes for facet joint injections and medial branch nerve blocks listed in the policy are the codes affected by any prior authorization process governed by this section and should be used when submitting prior authorization requests.

Use the CPT codes in the policy coding tables (e.g., 64490–64495 for fluoroscopy/CT guidance) when requesting authorization or submitting claims.

Step Therapy

Second diagnostic block required to confirm response before RFA

A second diagnostic facet joint injection/medial branch nerve block must be performed to confirm an initial positive response (≥80% pain relief for the expected anesthetic duration) before considering radiofrequency denervation/ablation at the diagnosed level(s).

The second diagnostic block should only be performed with intent to proceed to RFA if successful.
Document percent relief and duration for both injections.

Step Therapy

When RFA is contraindicated — two sequential diagnostics and therapeutic interval requirements

When radiofrequency ablation/neurotomy is contraindicated (e.g., established pseudoarthrosis or implanted electrical device), two sequential diagnostic blocks with documented positive responses (≥80% relief) may be used and subsequent therapeutic injections are allowed only if performed ≥6 months after prior therapeutic injection and prior relief ≥50% for ≥12 weeks.

Document the specific contraindication (pseudoarthrosis or implanted electrical device).
Document two sequential ≥80% responses to diagnostic blocks; for subsequent therapeutics document ≥50% relief for ≥12 weeks and ≥6‑month interval.

Documentation Required

Required documentation — document positive diagnostic responses and durations

Documentation must include evidence of a positive response to diagnostic injections — at least 80% relief for at least the expected minimum duration of the local anesthetic used — and record of prior injection responses when requesting subsequent procedures.

Record percent pain relief and duration correlated to the anesthetic used.
Include documentation of responses to the initial and second diagnostic blocks when applicable.

Documentation Required

Required clinical documentation — pain duration, conservative therapy, imaging correlation, fusion status

Clinical documentation must show duration of pain (≥3 months for initial diagnostic), prior conservative treatments and their duration (≥4 weeks in the prior 3 months) or documented contraindication, clinical correlation with imaging when indicated (e.g., synovial cyst causing nerve root compression), and that requested levels are not posteriorly fused.

If conservative therapy was contraindicated, document the reason(s).
For synovial cyst aspiration, include advanced imaging confirming compression/displacement of the nerve root and clinical correlation of radicular symptoms.

Documentation Required

Coding list does not replace clinical documentation requirements

The coding section primarily enumerates procedure codes for facet joint injections and medial branch blocks and does not itself specify additional documentation requirements beyond those in the Indications and Documentation sections.

Do not rely on the code table alone — include clinical documentation that meets coverage criteria when submitting requests.

Denial Risk

Denial triggers — non‑compliance with guideline criteria and procedural limits

Requests that do not meet the guideline criteria (e.g., not for facet‑mediated pain), that exceed allowed diagnostic injections (more than two at the same level), that exceed three facet levels per session, or are performed outside C2‑3 to L5‑S1 may be denied.

Verify indication is facet‑mediated pain and that the number and levels requested comply with policy limits.
Requests outside covered spinal levels (C2‑3 to L5‑S1) or exceeding three levels per session risk denial.

Denial Risk

General denial risk — missing required criteria or guidelines

Requests that do not meet the Definitions, General Guidelines, and Indications sections are considered not medically necessary and may be denied; ensure all prerequisite criteria are documented.

Therapeutic injections following the initial two diagnostic injections are not covered unless they meet alternative criteria (e.g., RFA contraindication with documented requirements).

Denial Risk

Ultrasound guidance — experimental/investigational denial risk

Facet joint injections/medial branch nerve blocks performed with ultrasound guidance are considered experimental, investigational, or unproven and may be denied.

Ultrasound‑guided procedure codes (0213T, +0214T, +0215T, 0216T, etc.) are listed in coding tables but ultrasound guidance is labeled EIU and may not be covered.

Note

Coding list lacks explicit denial triggers — rely on coverage criteria

The code tables in these chunks primarily list procedure codes and do not themselves state explicit denial triggers; use the Indications, General Guidelines, and Documentation sections to determine coverage and denial risk.

Codes alone do not establish medical necessity; provide supporting clinical documentation when submitting requests.

Anatomic scopeApplies to facet joints from C2-3 to L5-S1

inv-41: Non-Radicular Back Pain

DefinitionAxial (non-radicular) cervical, thoracic, or lumbar pain not causally related to spinal nerve root irritation and without reproducible dermatomal neuropathic findings

Clinical featuresMay include local paraspinal tenderness, pain increased by hyperextension/rotation/lateral bending, stiffness, and absence of neurologic deficit

RelevanceUsed to identify candidates for diagnostic facet joint injection/MBB when other causes have been excluded

inv-42: Initial diagnostic facet joint injection/medial branch nerve block

PurposeProcedure performed to determine whether chronic cervical, thoracic, or lumbar axial pain is of facet joint origin

PrerequisitesPain persisted >= 3 months and at least 4 weeks of conservative therapy in past 3 months (or documented contraindication)

Clinical requirementsClinical findings and imaging must suggest no other obvious cause; spinal motion segments at requested levels must not be posteriorly fused

inv-43: Second diagnostic facet joint injection/medial branch nerve block

PurposeRepeat diagnostic block at the same level(s) to confirm validity of the initial clinical response

Positive response requiredInitial diagnostic block must have produced a positive response (>=80% relief for expected LA duration)

Next stepA second diagnostic block is required before considering radiofrequency denervation/ablation

inv-44: Facet joint injection with synovial cyst aspiration

IndicationFacet joint injection performed with aspiration when advanced imaging (MRI/CT/CT myelogram) confirms a facet joint synovial cyst compressing or displacing the corresponding nerve root

Clinical correlationHistory and physical exam must correlate with signs and symptoms of radicular pain/radiculopathy

Repeat aspiration criterionRepeat aspiration is medically necessary when prior aspiration produced >=50% pain relief for at least 12 weeks

inv-45: Facet joint (zygapophyseal) injection / medial branch block

General definitionInjection(s) of diagnostic or therapeutic agent into the paravertebral facet (zygapophyseal) joint or the medial branch nerves that innervate the joint

Image guidancePerformed with image guidance (fluoroscopy, CT, or ultrasound) as specified by coding and procedure guidance

ScopeApplicable to facets from C2-3 to L5-S1 and includes both diagnostic and therapeutic injections