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

Coverage Summary

This is a UnitedHealthcare Community Plan, Louisiana–specific medical policy (Policy CS178LA.S) that defines coverage and medical necessity criteria for diagnostic and therapeutic Facet Joint Injections (FJIs) and Medial Branch Blocks (MBBs). The policy distinguishes diagnostic uses (including initial and confirmatory blocks intended to identify facet-mediated pain and to select patients for radiofrequency denervation) from therapeutic uses (intended to treat chronic facetogenic pain), and characterizes the overall evidence as mixed — supportive for diagnostic validity in select lumbar indications but limited or variable for therapeutic benefit. The policy was issued with an effective date of 2025-07-01 and is listed as CURRENT.

Medical Necessity Criteria

Initial diagnostic Facet Joint Injection/Medial Branch Block (Medically necessary)

Covered when ALL of the following are met:

ALL of the following

Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation)
Clinically significant improvement has not occurred (the pain remains at a 3 or more on a 1-10 pain scale) after a minimum of four weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy)>= 3 on 1-10 after >=4 weeks conservative care
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
A radiofrequency joint denervation/ablation procedure is being considered

Second Facet Joint Injection/Medial Branch Block to confirm validity (Medically necessary)

Covered when ALL of the following are met:

ALL of the following

Initial block positive response requirements
- The initial diagnostic Facet Joint Injection produced a positive response>= 50% relief for at least expected minimum duration
- For at least the expected minimum duration of the effect of the local anesthetic
- Functional improvement that is specific to the individual with demonstrable improvement in the physical functions previously limited by the facetogenic pain
Administered at the same level and side as the initial block

Diagnostic Medial Branch Blocks

Covered when ALL of the following are met:

ALL of the following

Dual blocks are performed in the same location(s) on two separate occasions due to high false positive rate of single diagnostic anesthetic injections in the spine.
A second confirmatory injection is indicated only if the first injection produces ≥ 80% relief of the primary (index) pain and the onset and minimum duration of relief is consistent with the agent employed.>= 80% relief
The confirmatory block confirms the tested joint as the source if the index pain is reduced by > 80%.> 80% reduction
A second injection may be performed at a different or additional level if pain is believed to arise from a different joint and pain relief from the initial block was < 80%.

Therapeutic Medial Branch Blocks

Coverage and medical necessity considerations:

ALL of the following

Therapeutic MBBs are performed in the same manner as diagnostic MBBs and are intended to achieve long term pain management.
Current evidence does not support their use as a therapeutic intervention.
Thoracic considerations: For thoracic pain: no published literature addresses intra-articular injections; medial branch block studies are limited to retrospective studies and case series — clinicians should weigh risks/benefits compared to other palliative care for thoracic spine pain with limited remaining treatment options.
Guideline references: NASS 2020: insufficient evidence to make recommendations for or against several uses including using reproduction of pain during zygapophyseal injection as predictor, using 50% relief following a single diagnostic injection as diagnostic threshold, steroid injections utility, and use of radiofrequency neurotomy or periarticular phenol after single diagnostic injection.

Therapeutic Facet Joint Injections/Medial Branch Blocks (Medically necessary)

The following therapeutic uses are proven and medically necessary:

ANY of the following

After two Facet Injections/Medial Branch Blocks at the same level and same side (considered therapeutic rather than diagnostic)
Therapeutic Facet Joint Injections and/or Facet Nerve Block (Medial Branch Block) for treating chronic spinal pain
For a second Facet Joint Injection/Medial Branch Block if the initial injection did not confirm the joint as the source of pain
In the presence of untreated Radiculopathy at the same level as the intended diagnostic injection (with the exception of Radiculopathy caused by a facet joint synovial cyst)
If injection volume of local anesthetics exceeds 0.5 ml for Medial Branch Blocks

Unproven / Not Medically Necessary

Not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Facet Joint/Medial Branch Blocks if radiofrequency ablation procedure is not considered as a treatment option at the requested level(s)
Facet Joint/Medial Branch Blocks for treating spinal pain after diagnostic injections have been completed
Therapeutic Facet Joint/Medial Branch Block injections at the cervical, thoracic, and lumbar levels are unproven and not medically necessary due to insufficient evidence of efficacy and safety

Coding

CPT/HCPCS - Ultrasound guidance (CPT-like codes, may not be on LA fee schedule)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), ... with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)
0215T	Injection(s), ... with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
0216T	Injection(s), ... with ultrasound guidance, lumbar or sacral; single level
0217T	Injection(s), ... with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)
0218T	Injection(s), ... with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

CPT - Image guidance (fluoroscopy or CT)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	..., cervical or thoracic; second level (List separately in addition to code for primary procedure)
64492	..., cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
64493	..., lumbar or sacral; single level
64494	..., lumbar or sacral; second level (List separately in addition to code for primary procedure)
64495	..., lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

ICD-10 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

1–10 of 15

1/2

Procedure / Diagnosis Codesmixed

No codes listed

Billing Rule

Code selection and state fee schedule

Codes affecting claims for facet joint injections and medial branch blocks include CPT-like ultrasound guidance codes and standard CPT image-guidance codes. Affected codes: 0213T-0218T and 64490-64495. Note: CPT-like codes 0213T–0218T are not on the Louisiana Medicaid Fee Schedule and therefore may not be covered by the State program; use the appropriate CPT/image-guidance codes per state rules and payer guidance.

Affected codes: 0213T–0218T (CPT-like ultrasound guidance codes)
Affected codes: 64490–64495 (CPT image-guidance codes)
CPT-like codes (0213T–0218T) are not on the Louisiana Medicaid Fee Schedule and may not be covered by the State program
Use appropriate CPT/image-guidance codes per state rules and payer guidance

Provider Actions & Documentation Requirements

Prior Authorization

Consideration of RFA required

Prior authorization/coverage is contingent on documentation that a radiofrequency denervation/ablation (RFA) procedure is being considered as a treatment option at the tested level(s) for diagnostic injections and for the confirmatory second block.

Documentation Required

Conservative care trial documentation

Document a minimum four-week trial of conservative care and that pain remains at least 3/10 on a 1–10 pain scale prior to the initial diagnostic injection.

Minimum four weeks of conservative care (e.g., pharmacotherapy, exercise, physical therapy)
Pain remains ≥ 3/10 after conservative care

Background, Evidence Summary & Definitions

Facet joint injections and medial branch blocks are used both diagnostically (to identify facet joint–mediated pain) and therapeutically (to attempt pain relief), with imaging guidance and local anesthetic standard for these procedures. Diagnostic blocks (including medial branch blocks) are generally considered more appropriate for prognosis and selection of patients for radiofrequency ablation; therapeutic benefit is variable and limited across studies. Multiple specialty society guidance is summarized in the policy: ASIPP and ASRA provide detailed recommendations on diagnostic techniques, volumes, conservative therapy preconditions, and cautious use of therapeutic injections; NASS recommends dual confirmatory blocks with an ≥ 80% relief threshold for confirmation and states current evidence does not support therapeutic MBBs; AANS/CNS endorses double-injection technique with an 80% improvement threshold for diagnosis; and ACOEM generally does not recommend routine therapeutic FJIs for acute, subacute, or chronic non-specific axial pain.

Citation	Key Finding
Cohen et al. 2018 RCT	Diagnostic facet or medial branch blocks are not therapeutic but are predictive for selecting patients for radiofrequency ablation; similar short-term pain reduction across groups but higher responder rates for those selected for RFA.
Manchikanti et al. 2016 systematic review	Level I evidence for diagnostic validity of lumbar facet nerve blocks (with ≥75% pain relief in studies); therapeutic evidence variable (Level II-III).
Hayes 2018 (updated 2022)	Low-quality evidence suggests lumbar facet joint injections may provide short-term pain relief (3–6 months); insufficient evidence for thoracic/cervical regions.
Ultrasound guidance evidence	No demonstrated overall health benefit of ultrasound over fluoroscopy/CT; mixed accuracy results and operator dependence; further RCTs needed.
NASS 2020	Insufficient evidence to make recommendations for or against several uses; many recommendations graded I or B regarding diagnostic thresholds and therapeutic interventions.
WFNS 2020	Facet joint injections provide a useful diagnostic tool for low back pain.

Regarding ultrasound guidance, the policy notes there is no peer-reviewed evidence demonstrating overall health benefit of ultrasound guidance versus fluoroscopy or CT for spinal facet injections. Systematic reviews and studies report mixed accuracy and outcome results and emphasize that ultrasound-guided procedures are operator-dependent with a steep learning curve; consequently, no recommendation of superiority is made and further well-designed RCTs are needed.

Term	Definition
Acute Low Back Pain	Low back pain present for up to six weeks; early acute <2 weeks, late acute 2–6 weeks.
Conservative Therapy	Combination of medications (e.g., NSAIDs), physical therapy, spinal manipulation, CBT, or other individualized interventions.
Facet Joint Injections (FJIs)	Injection of local anesthetic and/or corticosteroid into the facet joint capsule; diagnostic positive defined as >=50% relief for expected duration of anesthetic.
Facet Nerve Block / Medial Branch Block	Injection of local anesthetic and/or corticosteroid along the nerves supplying the facet joints; diagnostic positive defined as >=50% relief for expected anesthetic duration.
Radicular Back Pain	Pain radiating from the spine into the extremity along a dermatome associated with an irritated nerve root.
Non-Radicular Back Pain	Pain not radiating along a dermatome; imaging/clinical exam show no nerve root compression.
Sub-Acute Low Back Pain	Low back pain >6 weeks but <=12 weeks after onset.

Revision History

07/01/2025Policy RevisionLatest

Added language clarifying listed circumstances are unproven and not medically necessary for facet joint injections/medial branch blocks due to insufficient evidence of efficacy. Also updated Clinical Evidence and References sections and archived previous policy version CS178LA.R.

2025-07-01Effective DateLatest

Policy effective date.