CurrentUnitedHealthcarePolicy CSNCTOO05.06

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

UnitedHealthcare Community Plan medical policy for North Carolina governing diagnostic and therapeutic facet joint injections and medial branch blocks (including guidance on ultrasound use), listing required clinical criteria for coverage, definitions, supporting evidence and applicable procedure and diagnosis codes.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCTOO05.06

Change TypeCoverage Rationale revised; references updated

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument at least four weeks of conservative care and pain >= 3/10, document facet-loading exam findings, and ensure RFA candidacy and confirmatory block criteria are recorded prior to ablation.

POLICY UPDATE CHANGES

05/01/2025: Coverage Rationale - Added language to clarify the listed circumstances are unproven and not medically necessary for Facet Joint Injections/Medial Branch Blocks due to insufficient evidence of efficacy.

10/01/2025: Related Policies - Updated reference link to reflect current policy title for Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (for North Carolina only).

50%Diagnostic positive response threshold

4 weeksMinimum conservative therapy before diagnostic injection

0.5 mLMax recommended volume for lumbar MBB

Therapeutic injections

insufficient evidenceTherapeutic MBB effectiveness

multipleGuideline sources cited

Coverage Summary

UnitedHealthcare Community Plan (North Carolina) Medical Policy CSNCTOO05.06 (Effective May 1, 2025) addresses Facet Joint Injections (FJIs) and Medial Branch Blocks (MBBs). The policy takes a mixed coverage stance: diagnostic facet joint or medial branch blocks are proven and medically necessary when specific clinical criteria are met (including conservative therapy, pain severity, facet-loading exam findings, and consideration of radiofrequency ablation), while injections performed with therapeutic intent (i.e., as treatment rather than to select patients for radiofrequency ablation) are considered unproven and not medically necessary due to insufficient evidence. Imaging guidance recommendations emphasize fluoroscopy or CT guidance (preferred) and note that ultrasound guidance is not supported by evidence/guidelines as equivalent in net health benefit.

Quick-reference thresholds and coverage stance

Diagnostic positive response>= 50% pain relief for at least the expected minimum duration of the local anesthetic

Minimum conservative therapy before diagnostic injection4 weeks (pain remains >= 3/10 after conservative care)

Pain severity prior to diagnostic injection>= 3 on a 1-10 pain scale after minimum conservative care

Max recommended lumbar MBB total volume< 0.5 mL total volume for lumbar medial branch blocks

Facet joint intra-articular (lumbar) volume< 1.5 mL to prevent capsular rupture and reduce spread

Therapeutic injections stanceTherapeutic facet joint/MBB injections are unproven and not medically necessary (not covered)

Medical Necessity Criteria

Proven and Medically Necessary - Initial Diagnostic Facet Joint Injection / Medial Branch Block

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).
Initial diagnostic Facet Joint Injection/Medial Branch Block
- Clinically significant improvement has not occurred after a minimum course of conservative care, and pain remains at or above the threshold.
- Conservative care duration>= 4 weeks
  Includes but is not limited to pharmacotherapy, exercise, or physical therapy.

Not Covered / Not Recommended Scenarios

Instructions for Use - Not Covered / Not Recommended Scenarios

These are situations where the policy indicates injections are not appropriate:

ANY of the following

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

Provider Actions & Billing Notes

Documentation Required

Document conservative therapy and pain score

Document at least four weeks of conservative care (e.g., pharmacotherapy, exercise, physical therapy) and that the patient’s pain remains 3 or greater on a 1–10 scale prior to performing an initial diagnostic facet joint injection or medial branch block.

Documentation Required

Document physical exam facet-loading findings

Document that pain is exacerbated by facet-loading maneuvers on physical examination (for example, hyperextension and rotation) to support selection for diagnostic facet joint/medial branch procedures.

Coding

Covered/Applicable Procedure Codes (image guidance fluoroscopy/CT; diagnostic/therapeutic facet joint injections)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 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)

Ultrasound-guided CPT Category III Codes (not on NC Medicaid fee schedule; may not be covered)CPTNot Covered

0213T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level (not on NC Medicaid Fee Schedule)
0214T	..., cervical or thoracic; second level (List separately) (not on NC Medicaid Fee Schedule)
0215T	..., cervical or thoracic; third and any additional level(s) (List separately) (not on NC Medicaid Fee Schedule)
0216T	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level (not on NC Medicaid Fee Schedule)
0217T	..., lumbar or sacral; second level (List separately) (not on NC Medicaid Fee Schedule)
0218T	..., lumbar or sacral; third and any additional level(s) (List separately) (not on NC Medicaid Fee Schedule)

Relevant 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

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Background and Evidence

Background: Facet joint injections and medial branch blocks are used both diagnostically (to identify facet-mediated pain and select candidates for radiofrequency denervation) and therapeutically (to attempt symptom relief). The policy summarizes society guidelines and evidence reviews regarding diagnostic validity and limited/variable therapeutic benefit. Imaging guidance for these injections typically uses fluoroscopy or CT; consensus guidance notes no demonstrated net health benefit for routine ultrasound guidance and identifies higher risk of incorrect needle placement with ultrasound in some analyses. Recommended injectate volumes include a maximum total volume for lumbar medial branch blocks of 0.5 mL and lumbar intra-articular facet joint volumes generally 1.5 mL to avoid capsular rupture. The policy also notes the FDA informational statement that the procedures themselves are not FDA-regulated, though devices, drugs, and tests used with the procedures may be regulated.

Source	Key takeaway
Cohen et al. 2018 RCT
Diagnostic facet/medial branch blocks are not therapeutic but can improve selection for radiofrequency ablation; small mean pain score changes at 1 month but higher responder rates when used to direct RFA
Manchikanti systematic reviews
Systematic evidence synthesis supports diagnostic validity of facet nerve blocks (level I for diagnostic validity in some analyses) but therapeutic efficacy evidence is variable and limited; some moderate evidence for RFA long-term benefit
Hayes technology assessment 2022 (update)
Low-quality evidence suggests lumbar facet joint injections may provide pain relief and functional improvement versus baseline with variable duration (3–6 months); magnitude and durability uncertain due to limited placebo-controlled trials
Ultrasound guidance evidence
No clear net health benefit of ultrasound vs fluoroscopy/CT for spinal injections; some analyses show higher risk of incorrect needle placement with US-guided MBB/FJI and operator dependence
NASS 2020
Insufficient evidence to recommend for or against many facet joint/medial branch injection uses; varied grades (e.g., suggests IA steroid provides no meaningful improvement at 6 months in selected patients; mixed recommendations on cutoff thresholds)
WFNS 2020
States facet joint injections provide a useful diagnostic tool for low back pain

Therapeutic Medial Branch Blocks

Therapeutic facet joint/medial branch block injections at cervical, thoracic, and lumbar levels are:

ALL of the following

Therapeutic facet joint/medial branch block injections at cervical, thoracic, and lumbar levels are considered unproven and not medically necessary due to insufficient evidence of efficacy and safety

Revision History

05/01/2025material_change

Coverage Rationale updated clarifying the listed circumstances are unproven and not medically necessary for Facet Joint Injections/Medial Branch Blocks due to insufficient evidence of efficacy; Supporting Information updated (Clinical Evidence and References) and prior policy version CSNCTOO05.05 archived.

10/01/2025related_policies_updateLatest

Related Policies updated: reference link changed to reflect current policy title for Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) (North Carolina only).

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSNCTOO05.06

Change TypeCoverage Rationale revised; references updated

Effective DateMay 1, 2025

Next Review Date

On This Page

Pain severity threshold>= 3/10

Pain remains at a score of 3 or more on a 1–10 pain scale after conservative care.

The spinal motion segment is not fused.

Clinical findings and imaging studies suggest no other cause of the pain (e.g., spinal stenosis with neurogenic claudication, radiculopathy due to nerve root compression).

A radiofrequency joint denervation/ablation procedure is being considered.

Proven and Medically Necessary - Second (Confirmatory) Facet Joint Injection / Medial Branch Block

Covered when ALL of the following are met:

ALL of the following

Administered at the same level and side as the initial diagnostic block.
Second (Confirmatory) Facet Joint Injection/Medial Branch Block
- Positive response to the initial diagnostic block
  - At least 50% relief of pain for at least the expected minimum duration of the effect of the local anesthetic used.>= 50%
  - Functional improvement specific to the individual, with demonstrable improvement in the physical functions previously limited by the facetogenic pain.
- A radiofrequency joint denervation/ablation procedure is being considered.

Unproven and Not Medically Necessary - Therapeutic Injections

The following are unproven and not medically necessary due to insufficient evidence of efficacy and safety:

ALL of the following

Therapeutic Facet Joint/Medial Branch Block injections at the cervical, thoracic, and lumbar levels of the spine are unproven and not medically necessary.

Unproven and Not Medically Necessary

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Therapeutic facet joint injections after diagnostic injections have been completed when a radiofrequency ablation procedure is NOT being considered at the requested level(s).
A second Facet Joint Injection/Medial Branch Block if the initial injection did not confirm the joint as the source of pain (considered not medically necessary).
Therapeutic Facet Joint/Medial Branch Block injections used to treat chronic spinal pain in lieu of or instead of radiofrequency ablation when RFA is not an option.

FDA statement (informational)

FDA: Injectable local anesthetics and corticosteroids used for facet joint or medial branch injections are subject to FDA labeling for each product; clinicians should follow approved indications and labeling for specific agents used. This policy’s coverage statements do not alter FDA approvals or product labeling and are informational only.

When performed under ultrasound guidance (listed as not appropriate in Instructions for Use)

If injection volume of local anesthetic exceeds 0.5 mL for Medial Branch BlocksMedial Branch Block volume >0.5 mL

Operationally, requests for facet joint or medial branch injections submitted without documentation meeting the diagnostic criteria (for example, lack of at least 4 weeks of conservative therapy, missing facet-loading exam findings, pain < 3/10 after conservative care, or no plan to consider radiofrequency ablation) or submitted for purely therapeutic intent are likely to be denied as not medically necessary per policy. Providers should expect denials when therapeutic injections are requested outside the listed exceptions and should follow UnitedHealthcare preauthorization and documentation requirements.

Prior Authorization

Prior authorization expectation for diagnostic sequence

Prior authorization reviewers expect documentation that radiofrequency ablation (RFA) is being considered as a treatment option and that diagnostic/confirmatory block criteria for RFA candidacy are met before proceeding to ablation.

Denial Risk

Denial risk for therapeutic injections

Therapeutic facet joint injections or medial branch blocks performed as treatment (rather than diagnostic procedures to select patients for RFA) are considered unproven and not medically necessary and may be denied.

Documentation Required

Confirmatory (second) block documentation

When a second (confirmatory) block is performed, document the initial positive response, that the duration of relief is consistent with the expected effect of the local anesthetic used, and demonstrable functional improvement specific to activities previously limited by the facetogenic pain.

Billing Rule

Ultrasound-guided Category III codes may not be covered

CPT Category III ultrasound-guided codes 0213T–0218T are not on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program; confirm coverage and billing rules prior to using these codes.

0213T
0214T
0215T
0216T
0217T
0218T

Documentation Required

Weigh risks/benefits for thoracic injections

For thoracic spine procedures, document the clinician’s rationale weighing risks and benefits before performing intra-articular or medial branch interventions because evidence for thoracic facet injections is limited; include this rationale in the medical record.

Prior Authorization

Coverage rationale updated (effective 05/01/2025)

Effective 05/01/2025 the policy clarifies that listed circumstances are unproven and not medically necessary due to insufficient evidence. Providers should expect denials when medical necessity criteria are not met and must follow UnitedHealthcare preauthorization processes.

Therapeutic MBBs are performed in the same manner as diagnostic MBBs and are intended to achieve long term management; current evidence does not support their use as a therapeutic intervention

Consensus and guideline sources note limited evidence for thoracic intra-articular injections and limited quality of studies for medial branch blocks

NASS 2020 Guideline Statements Related to Facet Joint/Medial Branch Injections

NASS recommendations and evidence grades summarized:

ANY of the following

In patients selected for facet joint procedures using diagnostic criteria of physical exam and a response to a single diagnostic intra-articular injection with 50% relief; it is suggested that intra-articular injection of steroids provides no clinically meaningful improvement at 6 months. Grade of Recommendation: B.
Patient-reported reproduction of pain during a zygapophyseal joint injection as a predictor of response to dual diagnostic blocks. Grade of Recommendation: !.
There is insufficient evidence to make a recommendation for or against the use of certain approaches (statement truncated in source).
Use of steroid injections into the zygapophyseal joint in patients with chronic back and a physical exam suggestive of facet-mediated pain. Grade of Recommendation: !.
Use of a 50% reduction in pain following medial branch blockade for the diagnosis of zygapophyseal joint pain. Grade of Recommendation: |
Use of uncontrolled medial branch blocks vs. pericapsular blocks for diagnosis of zygapophyseal joint pain based on outcomes of medial branch nerves cryoablation. Grade of Recommendation: i.

ref

WFNS 2020 Statement

ALL of the following

WFNS Spine Committee states that facet joint injections provide a useful diagnostic tool for low back pain

ref

Definitions / Glossary: • Facet Joint Injections (FJIs): injection of local anesthetic and/or corticosteroid into the facet joint capsule; considered diagnostic when there is ≥ 50% relief for the expected anesthetic duration. • Medial Branch Block (MBB) / Facet Nerve Block: injection of local anesthetic and/or corticosteroid along the nerves supplying the facet joints; diagnostic if ≥ 50% relief for the expected anesthetic duration. • Conservative Therapy: individualized combination of treatments such as medications (e.g., NSAIDs, analgesics), exercise, and physical therapy. • Radiculopathy: pain radiating from the spine along a spinal nerve root producing symptoms away from the source. • Acute Low Back Pain: low back pain present up to six weeks (early acute <2 weeks; late acute 2–6 weeks).