UnitedHealthcare facet joint injections Coverage Update

Coverage Criteria

Coverage criteria (diagnostic, therapeutic, imaging guidance)

Covered when ALL of the following are met for diagnostic use or therapeutic consideration:

Diagnostic use and selection: Diagnostic facet joint or medial branch blocks may be used to diagnose facetogenic pain and to select patients for radiofrequency denervation based on a positive response (>=50% relief for at least the expected duration of the local anesthetic).>=50% pain relief

Supported by randomized trials and consensus guidance (Cohen et al. 2018; ASIPP; NASS)

Therapeutic use: Therapeutic facet joint or medial branch injections have insufficient and low-quality evidence to demonstrate consistent long-term effectiveness; may provide variable short-term (eg, 3–6 months) relief in some lumbar cases but overall effectiveness and durability are uncertain.

Hayes technology assessment and guideline reviews report low-quality and variable-duration benefit

Imaging guidance modality: Facet joint and medial branch injections performed under ultrasound guidance are considered unproven and not medically necessary due to insufficient evidence and higher risk of incorrect needle placement compared with fluoroscopy or CT.

Systematic review/meta-analysis (Ashmore et al. 2022) found 11–13% higher risk of incorrect needle placement with ultrasound vs fluoroscopy/CT

Diagnostic confirmation and therapeutic use

Coverage considerations structured around diagnostic confirmation and therapeutic use

Diagnostic medial branch blocks / confirmatory blocks: A second confirmatory (dual) diagnostic injection is indicated when the first injection produces >=80% relief and the onset and duration of relief are consistent with the local anesthetic; dual blocks are recommended due to the high false-positive rate of single diagnostic injections.>=80%

ASIPP and consensus guidelines support confirmatory dual blocks to improve diagnostic specificity

Therapeutic medial branch blocks are not supported by high-quality evidence as a consistently effective long-term treatment; society guidance is mixed (some societies report moderate evidence for selected lumbar/cervical indications while others state insufficient evidence).

Consider conditional or limited use only when documentation and rationale align with guideline recommendations

Use of steroids and intra-articular injections: Guidelines (VA/DoD, ACOEM, ASRA) generally recommend against routine intra-articular corticosteroid injections and routine steroid use with medial branch blocks; steroid use may be considered in select patients with documented rationale.

The policy distinguishes diagnostic use from routine therapeutic use and specifies imaging guidance expectations. For diagnostic purposes, medial branch blocks (MBB) and facet joint injections (FJI) may be used to identify facetogenic pain and to select patients for subsequent procedures such as radiofrequency denervation when a diagnostic block produces ≥50% pain relief for at least the expected duration of the local anesthetic. The policy also notes that therapeutic facet joint injections have an overall limited and low-quality evidence base: some lumbar studies report short-term benefit (typically up to 3–6 months) but the magnitude and durability of effect are uncertain.

With respect to imaging guidance, the policy states that procedures performed under ultrasound guidance are considered unproven and not medically necessary because there is no demonstrated net health benefit versus fluoroscopy/CT and pooled analyses show higher rates of incorrect needle placement with ultrasound guidance. Fluoroscopy or CT guidance is preferred for most facet procedures; cervical MBB guidance may be more permissive in guideline statements but the policy emphasizes the limited evidence for ultrasound overall.

Specialty society guidance is referenced to frame diagnostic confirmation and therapeutic recommendations. Some societies (AANS/NASS/ASIPP) support confirmatory dual diagnostic blocks when the initial block produces a very large treatment effect; the policy notes that a second confirmatory block is generally indicated when the first produces ≥80% relief and the onset/duration match the anesthetic used to reduce false positives.

Therapeutic use of medial branch blocks or intra-articular steroid injections is not uniformly supported across societies. The policy highlights mixed guidance: several organizations and guideline documents advise against routine corticosteroid intra-articular facet injections or therapeutic MBBs (for example, the VA/DoD and ACOEM statements), and NASS characterizes the evidence as insufficient to make a strong recommendation for therapeutic MBBs in many contexts. When steroids are used, the policy advises documenting the clinical rationale because routine use is not recommended.

The cited reference section contains the bibliography and guideline citations but does not list any additional explicit exclusions beyond those stated elsewhere in the policy text. The policy therefore relies on the documented guideline statements and evidence summaries for exclusionary recommendations rather than adding separate exclusion listings in these reference chunks.

The source explicitly identifies ultrasound-guided facet joint/medial branch procedures as unproven and not medically necessary due to insufficient evidence of efficacy. Separately, therapeutic facet joint and medial branch injections are described as having insufficient or low-quality evidence to demonstrate long-term effectiveness; guideline statements from organizations such as ACOEM and VA/DoD recommend against routine intra-articular corticosteroid injections or therapeutic MBBs in many presentations, supporting a conservative coverage stance for routine therapeutic use.

The evidence synthesis and guideline excerpts do not support therapeutic medial branch blocks as an effective long-term therapy. The NASS guidance and evidence reviews indicate insufficient evidence to recommend therapeutic MBBs or intra-articular injections for thoracic pain and limited evidence for other regions. Hayes and other assessments conclude that lumbar intra-articular injections may offer variable short-term relief but overall evidence quality is low and long-term benefit is uncertain, reinforcing the policy’s conservative approach toward therapeutic injections.

Multiple cited analyses and guideline statements emphasize that the current evidence base does not support ultrasound-guided injections as equivalent to fluoroscopy/CT guidance; pooled data show higher incorrect placement rates for ultrasound with low to very low certainty. For therapeutic MBBs and intra-articular injections, systematic reviews and technology assessments note low-quality or insufficient evidence to establish consistent clinical benefit, particularly for thoracic and cervical indications.

Coding and Diagnosis

Applicable procedure CPT/HCPCS codesmixed

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.
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).
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.

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Listed ICD-10 diagnosis codesICD-10

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

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Positive diagnostic block threshold

Positive diagnostic threshold>= 50% pain relief for at least the expected duration of the local anesthetic

ApplicationApplies to diagnostic facet joint injections and medial branch (facet nerve) blocks

Documentation requirementDegree of pain relief and expected anesthetic duration must be recorded to support a positive block

Diagnostic relief thresholds

Confirmatory block threshold>= 80% reduction of the index pain on the first block with onset/duration consistent with the agent before performing a second confirmatory injection

Role of dual/confirmatory blocks

Provider Actions and Documentation

Documentation Required

Conservative therapy documentation

Documentation must include prior conservative therapy and clinical justification for target levels. For lumbar procedures document a trial of conservative therapies (e.g., activity modification, physical therapy, NSAIDs/analgesics, weight loss, sleep hygiene) of at least 3 months per ASRA guidance. For cervical procedures document at least a 6-week trial of conservative therapy (individualization allowed). Include prior imaging and rationale for selected vertebral levels.

Document type and dates of conservative therapies tried
If deviating from timing (e.g., urgent indications), provide rationale

Denial Risk

Ultrasound-guided procedures — denial risk

Ultrasound-guided facet joint injections or medial branch blocks are considered unproven and not medically necessary due to insufficient evidence of efficacy and higher risk of incorrect needle placement versus fluoroscopy/CT; use fluoroscopic or CT image guidance per policy unless a plan-specific exception applies.

Definitions

Facet Joint Injections (FJIs) definition

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

Diagnostic useFJIs can be used to diagnose facet-joint pain but are generally less predictive than medial branch blocks

Positive diagnostic criterionConsidered positive when >=50% relief of pain for at least the expected minimum duration of the local anesthetic

Medial Branch Block (MBB) definition

DefinitionInjection of local anesthetic and/or corticosteroid along the nerves supplying the facet joints (medial branch nerves)

Diagnostic criterionDiagnostic MBB is positive when there is >=50% relief of pain for at least the expected duration of the local anesthetic

Conservative Treatment Requirements

Document prior conservative therapy and rationale for proceeding to injections — 3 months (ASRA) or >=6 weeks for cervical per consensus

Document prior conservative therapy and rationale for proceeding to injections:

General conservative therapy duration: Document a trial of conservative therapies (eg, medications, physical therapy, exercise, behavioral measures) prior to facet interventions as clinically appropriate; ASRA recommends approximately a 3‑month trial of conservative treatments before considering facet procedures.3 months

Document therapies tried, duration, and response

Cervical pain specific: For cervical spine pain, document at least a 6‑week trial of conservative therapy (may vary by individualized care); include rationale if proceeding earlier or when additional factors (eg, anticoagulation, implants, limited access to RFA) justify intervention.>=6 weeks

Consensus cervical guidance recommends at least 6 weeks prior conservative therapy and preprocedural imaging for AO/AA injections

Frequency and Utilization

Therapeutic facet joint/medial branch nerve blocks — typical courses

Typical course reportedApproximately 3-6 injections per year reported in therapeutic lumbar facet/medial branch studies (e.g., averages ~3.7 to 5-6 injections/year in trials)

Duration of relief per episodeManchikanti trials reported average relief ~19 weeks per treatment episode or variable durations up to ~82-84 weeks in some cohorts

Evidence qualityTherapeutic injections show variable/low-quality evidence; routine use not routinely recommended by some societies

Intra-articular facet joint injections — frequency guidance

Frequency guidanceRoutine use of intra-articular facet joint injections is not recommended; when used, limit volumes and document rationale

Society recommendations

Imaging and Guidance Requirements

Billing Rule

Use fluoroscopy or CT guidance; ultrasound not supported

Perform facet joint and medial branch injections using fluoroscopy or CT guidance as preferred imaging modalities; ultrasound guidance is not supported by this policy for these procedures.

Policy favors fluoroscopy or CT guidance and notes lack of evidence of overall health benefit for ultrasound guidance during spinal injections.
Document the imaging guidance used; ultrasound-guided procedures may face noncoverage based on policy statements.

Billing Rule

Imaging guidance specifics — cervical exceptions and AO/AA imaging

For most facet joint injections and medial branch blocks, fluoroscopy or CT guidance is preferred; for cervical MBB, fluoroscopy or ultrasound is acceptable per consensus, and AO/AA injections require pre-procedural CT or MRI.

Not Covered / Unproven

Ultrasound-guided facet joint injections and medial branch blocks are described in the policy as unproven and not medically necessary because evidence does not demonstrate superiority or equivalent safety to fluoroscopy/CT guidance and pooled analyses (Ashmore et al.) report an increased risk of incorrect needle placement confirmed by fluoroscopy/CT.

The policy also states that therapeutic facet joint/medial branch injections across cervical, thoracic, and lumbar levels have insufficient evidence of efficacy and safety; lumbar intra-articular injections may sometimes produce short-term benefit but the overall evidence quality is low and the duration variable, supporting noncoverage or conditional coverage approaches for routine therapeutic injections.

This entry reiterates that ultrasound-guided facet procedures are considered unproven and not medically necessary because guidelines do not recommend routine ultrasound guidance and pooled data indicate higher incorrect placement rates versus fluoroscopy/CT. Guideline statements from societies such as ACOEM also caution against routine therapeutic intra-articular steroid injections in many clinical scenarios.

The policy restates that ultrasound guidance for facet joint and medial branch injections lacks sufficient evidence and therefore is considered not medically necessary. In addition, NASS and other reviews report limited or insufficient evidence supporting therapeutic medial branch blocks, particularly for thoracic indications, which supports a restrictive stance on routine therapeutic procedures.

The referenced bibliography and guideline list do not themselves enumerate additional procedures or indications that are explicitly labeled as not covered beyond the positions summarized elsewhere in the policy text. The absence of specific not-covered items in these reference chunks does not change the policy’s defined noncoverage statements.

Background

Facet joint injections (FJIs) and medial branch blocks (MBBs) are procedures that introduce local anesthetic, with or without corticosteroid, into the facet joint capsule or along the medial branch nerves to diagnose or potentially treat facetogenic spinal pain. Diagnostic blocks are interpreted as positive when the procedure produces ≥50% pain relief for at least the expected duration of the local anesthetic, and confirmatory dual blocks (often requiring ≥80% relief on the first block to justify a second) are recommended by some societies to reduce false-positive rates. Imaging guidance and documentation of technique, injected volumes, and prior conservative therapy are essential elements of procedural documentation. The policy references systematic reviews showing higher incorrect needle placement rates with ultrasound guidance compared with fluoroscopy/CT and summarizes guideline recommendations that generally discourage routine intra-articular steroid injections and therapeutic MBBs except in select circumstances with documented rationale.

Revision History and Policy Changes

2025-06-01Policy createdLatest

Policy created as a new medical policy (Summary of Changes: New Medical Policy).

OpenPayer

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