ModifiedUnitedHealthcarePolicy CS178KS.02

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

Medical policy governing facet joint and medial branch block injections for spinal pain in Kansas; describes coverage rationale, diagnostic and therapeutic evidence, coding, and documentation expectations for providers and reviewers.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178KS.02

Change TypeClarification and content updates (documentation/coverage governance)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument a trial and duration of conservative therapies (e.g., medications, physical therapy) and ensure legible medical record documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria.

Added reference link to the Reimbursement Policy titled Anesthesia Policy, Professional.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Kansasstate

>=50%diagnostic block threshold

0213T-0218T, 64490-64495procedure codes listed

3 months

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

05/01/2026policy revision date

Coverage Criteria for Facet Joint and Medial Branch Injections

Diagnostic Facet Joint/Medial Branch Block Criteria

Covered when ALL of the following are met (per InterQual criteria referenced):

InterQual referenced: Medical coverage for facet joint injections follows InterQual CP: Procedures, Facet Joint Injection for medical necessity criteria.

InterQual criteria referenced in policy; see InterQual for specific details

Diagnostic block interpretation: A diagnostic facet joint injection or 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.≥50%

Used to select patients for further procedures such as radiofrequency ablation

Therapeutic Facet Joint/Medial Branch Injection Coverage

Policy stance on therapeutic injections:

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

Policy cites multiple systematic reviews and trials finding inconsistent or low-quality evidence

Extracted clinical criteria and guideline recommendations

Summarized clinical guidance and evidence findings relevant to diagnostic and therapeutic facet interventions

Diagnostic medial branch blocks: Multiple specialty societies (ASIPP, NASS, ASRA) recommend diagnostic medial branch blocks for identifying facet-mediated pain; NASS and AANS/CNS recommend dual confirmatory blocks with an ≥80% relief threshold for confirmation. ASIPP supports diagnostic use for lumbar, cervical, and thoracic with varying strength.≥80% for confirmatory dual block per NASS/AANS; ≥50% considered positive by some societies

See referenced society guidance

Therapeutic medial branch blocks and intra-articular injections: Evidence is mixed: systematic reviews and technology assessments report variable, low-quality evidence with short-term (3–6 month) benefits in some studies; many societies recommend against routine use of therapeutic intra-articular injections and note insufficient evidence for routine therapeutic medial branch blocks.follow-up outcomes often reported at 3 months

See cited systematic reviews and technology assessments

Guideline statements (evidence and recommendations)

Guideline conclusions and recommendations from NASS and related bodies regarding facet joint and medial branch interventions

Therapeutic medial branch blocks: Current evidence does not support use of therapeutic medial branch blocks for long-term pain management.

NASS: insufficient evidence; limited to retrospective studies and case series

Thoracic intra-articular injections: No published literature addressing intra-articular injections for thoracic pain; clinicians should weigh risks/benefits compared with palliative care.

NASS statement

Diagnostic value and evidence grades: Multiple indications have grade I (insufficient) recommendations, including using reproduction of pain during injection as predictor, use of steroid injections, and use of 50% pain reduction criteria following medial branch blockade.

From NASS Evidence-Based Clinical Guidelines 2020

Facet Joint Injections/Medial Branch Blocks performed under ultrasound guidance are considered unproven and not medically necessary due to insufficient evidence of efficacy. This policy statement applies to ultrasound-guided procedures regardless of anatomic level and may result in claim denial when ultrasound guidance is used in place of image guidance modalities supported by the evidence base (for example, fluoroscopy or CT).

Multiple guideline panels have advised against routine use of corticosteroid injections for intra-articular facet joint procedures. The ACOEM 2021 guidance specifically lists intra-articular therapeutic facet joint injections as not recommended for acute/subacute low back pain and only moderately not recommended for routine treatment of chronic nonspecific axial pain. The VA/DoD 2022 guidance similarly suggests against the use of corticosteroids for intra-articular facet joint injections and for therapeutic medial branch blocks.

No additional exclusion statements are specified in this section of the policy excerpt.

Therapeutic facet joint and medial branch block injections at the cervical, thoracic, and lumbar levels are considered unproven and not medically necessary. Systematic reviews and guideline assessments report low-quality, inconsistent evidence and, in some cases, failed sham-controlled trials; professional societies recommend weighing risks and benefits and generally do not support routine therapeutic use.

The North American Spine Society (NASS) position is that current evidence does not support the use of therapeutic medial branch blocks as a treatment for long-term pain management. NASS notes limitations in the literature (mostly retrospective series and lack of robust randomized data) and assigns insufficient evidence grades for many therapeutic uses of facet and medial branch interventions.

Therapeutic medial branch blocks are not supported by current evidence as an effective therapeutic intervention. Systematic reviews have downgraded the quality of evidence for therapeutic facet procedures because of bias, inconsistency, and imprecision, and guideline panels conclude there is insufficient data to recommend routine therapeutic medial branch blocks.

Coding and Diagnosis Codes

Ultrasound-guided 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)... 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).

Fluoroscopy/CT-guided procedure codesCPT

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

Example diagnosis (ICD-10) 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.

1–10 of 15

1/2

inv-14: Diagnostic block positivity threshold — ≥ 50% pain relief for at least the expected minimum duration of the local anesthetic

Threshold≥ 50% pain relief for at least the expected minimum duration of the local anesthetic

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

PurposeUsed to identify facet-mediated pain and to select patients for further procedures such as radiofrequency ablation

inv-15: Positive block pain relief threshold(s) — ≥50% (ASRA often), ≥80% (AANS/CNS and NASS for confirmatory dual block)

ASRA guidance≥ 50% reduction in pain may be considered a positive block (ASRA)

Provider Actions, Documentation, and Authorization

Billing Rule

Procedure codes subject to review

Procedure codes for facet joint and medial branch injections are subject to review. Examples include CPT/T proprietary codes for ultrasound-guided and image-guided injections such as 0213T–0218T (ultrasound-guided facet joint injections), and CPT codes including 64490, 64491 (image-guided facet/medial branch injections).

Codes subject to review include: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T; 64490, 64491 (and related image-guided facet/medial branch injection codes).

Prior Authorization

Prior authorization and criteria source

Prior authorization may be required when documentation does not demonstrate completion of recommended conservative therapy duration or when preprocedural imaging is required but not documented. UnitedHealthcare uses InterQual® as the primary source for medical/surgical criteria; when InterQual does not apply, UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment may be used. Federal, state, or contractual requirements may govern prior authorization practices.

Background and Rationale

Facet joint and medial branch block injections are used diagnostically to identify facet-mediated pain and are sometimes used therapeutically. Diagnostic blocks are considered positive when they produce at least 50% pain relief for at least the expected duration of the local anesthetic, a threshold commonly used to select patients for subsequent procedures such as radiofrequency ablation. The policy references InterQual for detailed medical necessity criteria and notes that evidence for therapeutic benefit is limited and variable across spinal levels.

Definitions and Procedural Descriptions

inv-32: Facet Joint Injections — Definition and diagnostic positivity threshold

DefinitionInjection of local anesthetic and/or corticosteroid into the facet (zygapophyseal) joint capsule

Diagnostic interpretationDiagnostic facet joint injection is considered positive when there is at least 50% relief of pain for at least the expected minimum duration of the local anesthetic

Comparative noteFacet joint injections can be used diagnostically but medial branch blocks are generally considered more appropriate for diagnosis

inv-33: Facet Nerve Block / Medial Branch Block — Definition and diagnostic positivity threshold

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

Diagnostic positivity

Conservative Treatment and Prior Conservative Therapy

Documented trial recommended by specialty guidance

Documented conservative trial - lumbar: Documented trial of conservative therapies for at least 3 months prior to lumbar facet interventions (e.g., medications, physical therapy, integrative treatments).3 months

Per ASRA guideline recommendations; document treatments and duration in the medical record

Documented conservative trial - cervical: Documented trial of conservative therapies for at least 6 weeks (as part of a minimum 3-month conservative management period) prior to cervical prognostic blocks.≥6 weeks

Per ASRA guidance; document treatments and duration in the medical record

Documentation requirement:

Frequency and Limits

inv-41: Not specified in this portion of policy.

StatusNot specified in this portion of policy.

ContextThe policy excerpt does not provide frequency limits for facet joint or medial branch injection procedures in this section.

ActionRefer to applicable InterQual criteria or full policy for any frequency or interval limits

inv-42: Therapeutic medial branch blocks — frequency limits not specified in this portion

Frequency limitsNot specified in this portion of the policy for therapeutic medial branch blocks

Evidence noteTherapeutic medial branch blocks are not supported by current evidence as a therapeutic intervention (NASS); frequency limits therefore are not detailed here

Imaging and Guidance Requirements

Billing Rule

Use fluoroscopy or CT for guidance; ultrasound not recommended

Fluoroscopy or CT is the generally recommended imaging guidance for facet joint and medial branch injections; ultrasound is not recommended as the preferred guidance modality in this policy.

Policy describes imaging guidance and commonly used fluoroscopy/CT for these procedures.
Ultrasound-guided injections are specifically called unproven/not medically necessary.

Documentation Required

Obtain CT or MRI before C0–C1 and C1–C2 injections

For atlanto‑occipital (C0‑C1) and atlanto‑axial (C1‑C2) injections, preprocedural advanced imaging with CT or MRI should be obtained and documented to ascertain pathology and guide needle trajectory.

Obtain CT or MRI before performing C0–C1 or C1–C2 injections and include imaging in the medical record.

Services Not Covered

Not covered by this policy are facet joint/medial branch blocks performed with ultrasound guidance, which are labeled as unproven and not medically necessary. The policy also indicates that the routine use of therapeutic intra-articular facet injections and therapeutic medial branch blocks is not supported by the evidence and therefore not covered as a standard therapeutic intervention.

Revision History and Policy Changes

2026-05-01policy_revisionLatest

Related policy reference added (Anesthesia Policy, Professional) and operational clarifications added specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178KS.02

Change TypeClarification and content updates (documentation/coverage governance)

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument a trial and duration of conservative therapies (e.g., medications, physical therapy) and ensure legible medical record documentation to support medical necessity.

SourceLink

On This Page

Use of ultrasound guidance: No high-quality evidence demonstrates superiority of ultrasound guidance over fluoroscopy/CT; pooled analyses show increased risk of incorrect needle placement with ultrasound compared with fluoroscopy/CT. Ultrasound may reduce radiation exposure and be feasible in expert hands but is operator dependent.11–13% higher incorrect needle placement in pooled analyses

Operator-dependent technique; ultrasound considered unproven/not medically necessary in policy

Conservative therapy prior to intervention: Consensus guidelines (ASRA) recommend a trial of conservative treatments before facet joint interventions: generally a 3-month trial for lumbar interventions and at least a 6-week trial (within a 3-month conservative window) for cervical prognostic blocks.3 months (lumbar), ≥6 weeks (cervical)

Document trials of conservative therapy in the medical record

Imaging and procedural technique recommendations: Preprocedural advanced imaging (CT or MRI) is recommended prior to atlanto-occipital and atlanto-axial joint injections; recommended injectate volumes to limit spread are provided (lumbar medial branch <0.5 mL total; lumbar interarticular <1.5 mL; cervical medial branch ≤0.3 mL; cervical interarticular ≤1 mL). Fluoroscopy or CT is generally used; fluoroscopy or ultrasound is recommended for cervical medial branch block per society guidance.volume limits as listed

Follow imaging guidance recommendations where specified

Intra-articular steroid injections: In patients selected by physical exam and single diagnostic intra-articular injection with 50% relief, intra-articular steroids provide no clinically meaningful improvement at 6 months (Grade B).50% relief from diagnostic injection

NASS Grade B recommendation

AANS/CNS and NASS (confirmatory dual block)

Recommend dual (double) injections with an improvement threshold of ≥ 80% to confirm lumbar facet-mediated pain

Practice noteSome societies accept ≥50% for a single diagnostic block; ≥80% is required by others for confirmatory/dual-block paradigms

Prior authorization follows federal, state, or contractual requirements.
UnitedHealthcare primary criteria source: InterQual®.
If InterQual® lacks applicable criteria, UnitedHealthcare Medical Policies approved by KDHE may be used.

Denial Risk

Documentation insufficiency may lead to denial

Lack of adequate medical record documentation that fully supports medical necessity may result in denial of coverage. Records must be legible and made available upon request.

Medical record must document relevant history, physical exam, and results of pertinent diagnostic tests/procedures.
Documentation that does not fully support medical necessity may lead to denial; benefit coverage is determined by federal, state, or contractual requirements.

Denial Risk

Potential documentation gaps that may lead to denial

Potential documentation gaps that may lead to denial include failure to document a trial and duration of conservative therapies or absence of required preprocedural imaging for certain cervical injections.

Missing documentation of conservative therapy type and duration (e.g., medications, physical therapy, integrative treatments) — a 3-month trial is recommended for lumbar interventions and at least 6 weeks (or individualized) for cervical.
Lack of preprocedural advanced imaging (CT or MRI) where indicated (e.g., atlanto-occipital and atlanto-axial injections) may result in denial.

Documentation Required

Conservative therapy documentation

Document the trial and duration of conservative therapies prior to facet procedures. Conservative therapies may include medications, physical treatments, integrative therapies, and other noninvasive measures.

Document type of conservative therapies used (e.g., NSAIDs, antidepressants, exercise, physical therapy, acupuncture, spinal manipulation).
Document duration — ASRA recommends a 3-month trial before lumbar interventions; for cervical pain, at least a 6-week trial or individualized conservative management prior to prognostic blocks.
Record concomitant use of conservative measures when performing prognostic blocks.

Note

Conservative-first approach

Conservative-first approach is recommended before performing facet joint or medial branch interventions. ASRA recommends a trial of conservative treatment (eg, 3 months for lumbar interventions) and consideration of risks/benefits before routine use of therapeutic injections.

Recommend trial of conservative treatment prior to facet interventions (3 months for lumbar interventions).
Routine use of therapeutic facet injections is not recommended; reserve steroids or therapeutic injections for select patients at higher risk from alternative procedures or with strong likelihood of benefit.

A diagnostic medial branch (facet nerve) block is positive when there is at least 50% relief of pain for at least the expected minimum duration of the local anesthetic

TechniqueUses imaging guidance and targets the medial branch nerve; generally preferred over intra-articular facet injection for diagnosis

inv-34: Dual blocks — Dual (confirmatory) diagnostic medial branch blocks

DefinitionDual (confirmatory) blocks = two diagnostic medial branch injections performed in the same location on separate occasions to confirm diagnosis

Confirmatory thresholdA second confirmatory injection is indicated when the first injection produces ≥ 80% relief and onset/duration is consistent with the agent used; confirmation requires >80% reduction

Alternative usesSecond injection may be performed at a different/additional level if initial block produced <80% relief

inv-35: Positive block thresholds — Positive prognostic block defined variably; ASRA notes ≥50% while some societies prefer higher thresholds

Variable definitionsPositive prognostic block thresholds vary across societies: some consider ≥50% positive; others require ≥80% for confirmation

ASRA position>50% reduction in pain may be considered a positive block (ASRA)

Society consensus for confirmationAANS/CNS and NASS recommend an ≥80% improvement threshold for confirmatory/dual-block diagnosis

inv-36: Therapeutic medial branch blocks — Definition noting current evidence does not support therapeutic use

DefinitionTherapeutic medial branch blocks are performed like diagnostic medial branch blocks but aim for long-term pain management

Evidence stanceCurrent evidence does not support their use as a therapeutic intervention (NASS statement)

GuidanceMany societies recommend against routine therapeutic medial branch blocks due to insufficient high-quality evidence

inv-37: Facet joint injections — Injections into zygapophyseal joints used primarily as diagnostic tools per WFNS recommendations

DefinitionInjections into zygapophyseal (facet) joints used primarily as diagnostic tools for low back pain (WFNS recommendation)

RoleFacet joint injections provide a useful diagnostic tool for low back pain but are less predictive than medial branch blocks

ImagingImaging guidance is typically used to perform facet joint injections to identify probable pain source

Medical record must document the conservative therapies tried, duration, and response; lack of documentation may lead to denial or requirement for prior authorization.

Follow policy documentation and prior authorization guidance

Next stepConsult full policy or InterQual criteria for any coverage-specific frequency guidance

Documentation Required

Document imaging guidance and procedural details for diagnostic blocks

Facet joint injections and medial branch blocks are described as useful diagnostic tools; imaging guidance (for example, fluoroscopy) is commonly used and should be documented.

Document the imaging modality used for the procedure (fluoroscopy or CT preferred).
Describe procedural technique and injectate volumes as applicable per specialty guidance.