ModifiedUnitedHealthcarePolicy CS178KS.01

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

Medical policy governing coverage and clinical rationale for facet joint injections and medial branch blocks in Kansas; affects providers submitting claims to UnitedHealthcare for members in Kansas. Applies to diagnostic and therapeutic injections, guidance methods, and related coding references.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178KS.01

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

Key ActionDocument percent pain relief and duration for diagnostic blocks (positive = ≥50% relief for expected anesthetic duration) when submitting for authorization or claims.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

KansasPolicy applies only to

>=50%Positive diagnostic threshold

Not medically necessaryUltrasound guidance stance

InsufficientTherapeutic injection evidence

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Coverage and Medical Necessity Criteria

Diagnostic block coverage

Covered when ALL of the following are met (diagnostic context and evidence-based guidance):

Diagnostic Facet/Medial Branch Block: Used to diagnose facet joint–mediated spinal pain; considered positive when there is >=50% pain relief for at least the expected duration of the local anesthetic used.>=50%

Diagnostic blocks have evidence supporting diagnostic validity and prognostic value for selecting patients for radiofrequency denervation; refer to InterQual CP: Procedures, Facet Joint Injection for specific clinical coverage criteria.

Therapeutic injection coverage

Therapeutic facet joint/medial branch injections coverage stance:

Therapeutic Facet Joint/Medial Branch Injections: Therapeutic intra‑articular facet joint injections and therapeutic medial branch blocks have insufficient and low‑quality evidence to demonstrate consistent effectiveness for cervical, thoracic, or lumbar spine pain; therapeutic use is described in parts of this policy as unproven or not medically necessary.

Systematic reviews and technology assessments report variable, often short‑term benefit in lumbar studies with methodological limitations; evidence is insufficient for thoracic and cervical regions.

Guideline-based coverage considerations

Coverage and clinical-use considerations reflected from guideline recommendations and evidence summaries:

Conservative therapy before interventions: Consensus guidelines recommend a trial of conservative therapies (examples: medications, physical therapy, integrative therapies) prior to facet joint interventions.3 months / 6 weeks depending on guideline

ASRA recommends a 3‑month trial for lumbar interventions; cervical guidance allows at least a 6‑week trial with personalization per patient factors.

Diagnostic block criteria and confirmatory testing: Medial branch diagnostic blocks should use established percent‑relief thresholds and consider dual (confirmatory) blocks due to a high false‑positive rate for single injections.>=80% for confirmatory dual blocks; >=50% commonly considered a positive prognostic block

A second confirmatory injection is indicated only if the first injection produces >=80% relief and the onset/duration matches the anesthetic; dual blocks improve diagnostic specificity.

Ultrasound-guided facet joint and medial branch block injections are described in this policy as unproven and not medically necessary due to insufficient evidence of efficacy. Clinical guidance documents cited in the policy do not recommend ultrasound guidance for spinal facet injections, and comparative data show measurable rates of incorrect needle placement with ultrasound versus fluoroscopic or CT guidance.

The routine use of intra-articular corticosteroid injections for facet joint pain and the routine use of therapeutic medial branch blocks are not supported by the available evidence. Multiple guideline bodies (including ACOEM and VA/DoD) recommend against or indicate insufficient evidence for corticosteroid intra-articular injections or therapeutic MBBs for acute, subacute, or routine chronic nonspecific axial pain. Where used, therapeutic injections have shown variable, often short-term benefit in some lumbar trials, but overall the evidence is low quality and does not establish consistent long-term effectiveness.

Facet joint and medial branch block injections are procedural interventions and therefore are not subject to FDA approval as a procedure. FDA regulation may apply to individual drugs, devices, or tests used during the procedure, but FDA approval alone is not a basis for coverage of the procedure itself.

Therapeutic injections intended to provide long-term pain relief—whether intra-articular facet joint injections or therapeutic medial branch blocks—are considered to have insufficient evidence of efficacy across spinal levels. The literature shows some low-quality randomized trials in the lumbar region with variable duration of benefit, but evidence for thoracic and cervical therapeutic use is inadequate. Guideline panels have either found insufficient evidence to recommend therapeutic MBBs or recommended against routine therapeutic corticosteroid injections in many clinical contexts.

Restrictions on therapeutic use align with guideline recommendations that emphasize conservative care prior to intervention and caution about routine therapeutic injections. When therapeutic injections are considered, guidelines recommend careful patient selection, use of diagnostic blocks with specified percent-relief thresholds and, in some cases, confirmatory dual blocks. Where guidelines advise against routine therapeutic corticosteroid or medial branch injections (for example in acute/subacute or nonspecific chronic axial pain), those therapeutic uses should not be considered medically necessary.

Procedure and Diagnosis Codes

Applicable CPT/HCPCS procedure 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).
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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Applicable ICD-10 diagnosis codes (examples)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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Diagnostic block positivity — threshold and documentation

Diagnostic positivity threshold>= 50% reduction in pain for at least the expected minimum duration of the local anesthetic.

Documentation requiredRecord percent pain relief and duration consistent with the anesthetic used to support diagnostic interpretation.

Role in care pathwayPositive diagnostic blocks used to identify candidates for subsequent interventions (e.g., radiofrequency denervation) per InterQual and guideline references.

Documentation, Prior Authorization, and Billing Guidance

Note

Provider summary

The following documentation, prior authorization, and billing expectations are actionable items for providers submitting claims for facet joint injections and medial branch blocks.

Verify member benefit terms and prior authorization requirements based on the member’s federal, state, or contractual plan before scheduling services.
When prior authorization is required by the benefit plan, submit documentation of prior conservative therapy and diagnostic block results as indicated (see items below).
Retain and submit clinical records showing percent pain relief, timing/onset, and duration consistent with the local anesthetic used for any diagnostic injection.

Documentation Required

Applicable procedure codes (reference)

Applicable procedure and diagnosis codes used for facet joint and medial branch injections (including ultrasound and image-guided codes) are listed for reference only. Inclusion does not guarantee coverage; verify benefit terms.

Include CPT/HCPCS codes for image-guided (fluoroscopy/CT) facet injections and medial branch blocks when applicable (e.g., 64490–64495 series and other region-specific codes).

Clinical Background and Rationale

Facet joint injections and medial branch nerve blocks are used primarily as diagnostic tools to identify facet-mediated pain and sometimes as palliative therapeutic procedures. Diagnostic injections typically use local anesthetic and are considered positive when there is ≥50% pain relief for at least the expected duration of the anesthetic. Diagnostic block results can inform selection for subsequent interventions such as radiofrequency denervation; some guideline bodies recommend confirmatory (dual) blocks with higher percent-relief thresholds for definitive diagnosis.

Key Terms and Definitions

Facet Joint Injections (FJIs) — definition

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

Diagnostic criterionA diagnostic FJI is considered positive when there is at least 50% relief of pain for at least the expected minimum duration of effect of the local anesthetic used.

Clinical noteFJIs can be used diagnostically but medial branch blocks are generally considered more appropriate for diagnosis.

Medial Branch Block / Facet Nerve Block — definition

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

Diagnostic thresholdA diagnostic medial branch block is considered positive when there is at least 50% relief of pain for at least the expected minimum duration of the local anesthetic used.

Conservative Therapy Prerequisites

Trial of conservative therapy recommended prior to facet interventions

Trial of conservative therapy recommended prior to facet interventions:

Minimum conservative therapy trial: A trial of conservative therapies (examples: medications, physical treatments, integrative therapies) is recommended prior to facet joint interventions.Generally a minimum of 6 weeks to 3 months depending on guideline and spinal region

ASRA advises a 3‑month trial for lumbar interventions; cervical guidance suggests at least 6 weeks with individualized care and concomitant conservative measures.

Treatment Frequency and Utilization

Facet joint/medial branch injections — frequency and trial observations

Policy frequency limitsNo explicit numeric frequency limits stated in this policy section for facet joint/medial branch injections.

Trial reports - Manchikanti 2010Treatment in the trial required approximately 5 to 6 injections over the study period; average relief ~19 weeks per episode.

Trial reports - Manchikanti 2007Average number of treatments per year was 3.7; mean duration of pain relief per procedure ~14.8 ± 7.9 weeks (non-steroid group).

Observational frequency data — average treatments and duration

Observed treatments per yearAverage observed treatments ~3.7 per year in a prospective randomized trial.

Duration of relief per procedure

Guidance Modality and Imaging Preferences

Billing Rule

Imaging preference

Fluoroscopy or CT guidance is preferred over ultrasound for facet joint and medial branch injections; ultrasound is considered unproven and associated with higher rates of incorrect needle placement in pooled analyses.

Prefer fluoroscopy/CT image guidance codes (e.g., 64490–64495) for billing when image guidance is used.
Ultrasound guidance lacks high‑certainty evidence of equivalence and may be denied as unproven.

Documentation Required

Imaging specifics

Fluoroscopy or CT guidance is the standard for facet injections; for cervical AO/AA joint injections, obtain pre-procedural CT or MRI to guide needle trajectory as recommended by guideline statements.

For cervical AO/AA injections, document pre‑procedural advanced imaging (CT or MRI) when performed.

Services Considered Not Medically Necessary

NOT COVERED: Ultrasound-guided facet joint or medial branch block injections are considered unproven and not medically necessary in this policy. The policy notes no peer-reviewed evidence demonstrating overall health benefit of ultrasound guidance compared with fluoroscopy or CT, and clinical guidelines do not recommend ultrasound-guided facet injections.

NOT COVERED: Routine therapeutic intra-articular corticosteroid injections and routine therapeutic medial branch blocks for acute or subacute low back pain, or for routine treatment of chronic nonspecific axial pain, are not supported by the cited guidelines and may be considered not covered. ACOEM, VA/DoD, NASS and other bodies either recommend against these uses or find insufficient evidence to support routine therapeutic corticosteroid or medial branch injections.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178KS.01

Change TypeNew policy

Effective DateJun 1, 2025

Next Review Date

Key ActionDocument percent pain relief and duration for diagnostic blocks (positive = ≥50% relief for expected anesthetic duration) when submitting for authorization or claims.

SourceLink

On This Page

Use of therapeutic injections:

Multiple guideline bodies note limited or insufficient evidence to support routine therapeutic intra‑articular steroid injections or therapeutic medial branch blocks; recommendations vary by society and clinical context.

Some organizations (e.g., ACOEM, VA/DoD, NASS) recommend against routine therapeutic use or note insufficient evidence, while other groups (e.g., ASIPP) may support selected therapeutic use in certain lumbar or cervical cases.

Imaging/guidance expectations: Fluoroscopy or CT guidance is the standard for facet injections; ultrasound guidance lacks high‑certainty evidence of equivalence and is associated with measurable rates of incorrect needle placement versus fluoroscopy/CT.~11-13% increased risk difference of incorrect needle placement for ultrasound vs fluoroscopy/CT reported in pooled analyses

Ultrasound may reduce radiation exposure but requires operator expertise; current evidence does not demonstrate overall health benefit of ultrasound guidance for facet injections.

Ultrasound-guided codes (e.g., 0213T–0218T) are listed but note policy/coverage guidance regarding ultrasound use (see denial risks).

Prior Authorization

Prior authorization: conservative therapy and diagnostic block documentation

When prior authorization is required by the member’s plan, expect requests to document: failure of a trial of conservative therapy, diagnostic block results (percent relief and duration), and rationale for proceeding to therapeutic interventions or radiofrequency ablation.

Document a trial of conservative therapy (recommendation: approximately 3 months) such as medications, physical therapy, and integrative therapies prior to facet interventions.
Provide documentation of diagnostic medial branch or facet joint block results including percent pain relief (recorded as ≥50% or ≥80% where applicable), onset and duration of relief consistent with the anesthetic used, and the targeted spinal levels.
If dual (confirmatory) blocks are required by clinical guidance or the benefit plan, include records of both procedures and the qualifying relief (e.g., ≥80% relief for confirmatory block when that threshold is used).

Prior Authorization

Prior authorization determined by plan terms

Prior authorization requirements, coverage decisions, and any exceptions are determined by the member’s federal, state, or contractual benefit plan. This policy is informational and used to interpret standard UnitedHealthcare benefits; in the event of conflict, plan-specific terms govern.

Confirm whether the member’s plan requires prior authorization for diagnostic or therapeutic facet procedures before rendering services.
If plan terms conflict with this medical policy, follow the federal/state/contractual plan requirements that govern coverage determination.

Note

Reference to InterQual criteria

UnitedHealthcare references InterQual CP: Procedures, Facet Joint Injection for clinical coverage determinations. Providers should use InterQual criteria in conjunction with submitted documentation when requesting authorization or appealing denials.

When InterQual criteria are applicable, include the clinical details InterQual requires (symptom duration, prior conservative therapy, diagnostic block response, neurologic findings).
If InterQual lacks applicable criteria, UnitedHealthcare may use approved UnitedHealthcare Medical Policies as noted in plan instructions.

Documentation Required

Conservative therapy trial recommended

Consensus guidance recommends a trial of conservative therapy prior to facet interventions; include documentation of therapies tried and response.

Recommended conservative therapies: medications (NSAIDs, antidepressants), exercise/physical therapy, integrative treatments (acupuncture, spinal manipulation if indicated), and lifestyle measures (weight loss, sleep hygiene).
Document duration and outcome of conservative treatment trial (commonly a 3-month trial as per consensus guidance).

Documentation Required

Documentation for diagnostic block positivity and coding

Diagnostic blocks must document percent pain relief and timing. Dual (confirmatory) medial branch blocks are required by many standards to confirm diagnosis due to high false-positive rates of single injections.

Record the percentage of pain relief and ensure onset and minimum duration are consistent with the anesthetic used (e.g., short-acting vs long-acting agents).
Consider a positive diagnostic block as ≥50% relief for some uses; for confirmatory dual blocks and certain guidance, an ≥80% relief threshold may be required before proceeding to radiofrequency ablation.
If a second confirmatory block is performed, document that it was performed at the same location(s) on a separate occasion and that relief meets the required threshold.
If initial block relief is <80% and different joints are suspected, a second block at alternative levels may be appropriate—document rationale and findings.

Denial Risk

Denial triggers: ultrasound guidance and therapeutic injections

Claims for facet joint or medial branch injections performed under ultrasound guidance or for therapeutic injections may be denied where the evidence is insufficient or plan terms exclude coverage.

Ultrasound-guided facet joint/medial branch injection codes (e.g., 0213T–0218T) may be subject to denial as unproven and not medically necessary per policy guidance.
Therapeutic facet joint/medial branch injections at cervical, thoracic, and lumbar levels may be considered unproven and not medically necessary—provide strong supporting clinical justification and verify benefit terms prior to submission.
Denials may result if documentation does not support the medical necessity criteria referenced (e.g., lack of documented conservative therapy, inadequate diagnostic block documentation).

Documentation Required

Document pain relief, timing, and targeted levels

Document pain relief percent, timing/onset, and targeted levels clearly in the medical record to support medical necessity determinations and billing.

Specify the targeted spinal levels and laterality for each injection performed.
Include progress notes showing the patient’s baseline pain, numerical pain scores, and the measured change after diagnostic injections with timeframe.
Attach imaging or fluoroscopy reports when image guidance was used, and clearly identify the guidance modality on the claim.

Note

Documentation and benefit verification

When coverage decisions or claim adjudications are made, UnitedHealthcare will reference the applicable federal, state, or contractual benefit terms; verify and provide documentation when there are conflicts or appeals.

If a requested service is denied, include all supporting clinical documentation and reference applicable plan provisions when submitting an appeal.
Keep copies of prior authorization approvals and the clinical basis for those approvals to attach to claims as needed.

SynonymMedial Branch Block is referred to as Facet Nerve Block in the policy.

Dual (confirmatory) medial branch blocks — definition

DefinitionTwo separate diagnostic injections at the same location performed on separate occasions to confirm the joint as the pain source.

Confirmatory criterionSecond confirmatory injection is indicated only if the first injection produces >= 80% relief and the onset/duration of relief matches the anesthetic used.

PurposeUsed because single diagnostic anesthetic injections have an unacceptably high false-positive rate; dual blocks improve diagnostic specificity for RFA selection.

Positive block threshold — guideline variability

Common positive threshold>= 50% reduction in pain is often considered a positive prognostic block by several societies.

Confirmatory threshold>= 80% reduction in pain is required by some bodies (e.g., NASS, AANS/CNS) to proceed with a second confirmatory block and to confirm diagnosis.

Guideline variabilitySocieties differ: ASRA notes >50% as positive for prognostic blocks while others recommend higher thresholds for confirmatory paradigms.

Diagnostic utility note — facet joint injections

Diagnostic utility statementFacet joint injections provide a useful diagnostic tool for low back pain.

Comparative noteMedial branch blocks are generally more predictive than intra-articular facet injections for identifying facet-mediated pain.

Clinical contextDiagnostic injections aid in determining the pain source and selecting appropriate subsequent interventions.

Mean duration of pain relief per procedure was 14.8 ±7.9 weeks in the non-steroid group (no significant difference vs steroid group).

Policy noteAlthough trials report multiple injections/year, the policy itself does not set a specific coverage frequency limit in this section.

Use fluoroscopy or CT rather than ultrasound for standard facet and medial branch injections.

Note

Lumbar-specific evidence

Comparative studies and meta-analyses evaluating ultrasound versus fluoroscopy/CT for lumbar facet joint injections show no clear patient‑level benefit for ultrasound and pooled analyses indicate measurable incorrect placement risk with ultrasound guidance.

Be prepared to provide procedural imaging confirmation (fluoroscopy/CT) if ultrasound-guided placement is questioned.
Document operator training/competence if performing ultrasound-guided injections, given variability in skill noted in the evidence.