ModifiedUnitedHealthcarePolicy CS178OH.D

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

This policy governs medical necessity, coding, and coverage stance for facet joint injections and medial branch blocks for spinal pain for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178OH.D

Change TypeDocumentation and related-policy updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity, including history, exam, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

Added explicit language that medical records documentation may be required to assess whether the member meets clinical criteria and that documentation must fully support medical necessity.

Added related policy links to Ablative Treatment for Spinal Pain (for Ohio Only) and Epidural Steroid Injections for Spinal Pain (for Ohio Only).

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

Ohio-onlyState-specific

InterQualPrimary criteria

Not coveredUltrasound guidance

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Therapeutic injections

≥50%Positive block threshold

≥80%Confirmatory block threshold

Coverage Criteria

Diagnostic/Therapeutic Coverage per InterQual

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

InterQual-based medical necessity: Medical necessity for facet joint injections and medial branch blocks is determined using InterQual CP: Procedures, Facet Joint Injection (refer to InterQual for detailed clinical entry criteria).

Use InterQual as the primary clinical coverage criteria; verify applicable federal, state (OAC), or contractual requirements that may affect coverage.

Explicit Not Medically Necessary Uses

Not medically necessary in the following explicit circumstances:

Unproven or not medically necessary uses: Facet Joint Injections/Medial Branch Blocks performed under ultrasound guidance; therapeutic facet joint/medial branch block injections at the cervical, thoracic, and lumbar levels of the spine.

These uses are explicitly identified in the policy as unproven and not medically necessary due to insufficient evidence of efficacy and/or safety.

General coverage considerations

Guidance summary and evidence-based considerations

Conservative therapy prerequisite: Consider facet or medial branch interventions only after appropriate conservative management trials (examples: medications, physical therapy, exercise, integrative treatments).

Examples of suggested durations include at least a 6-week trial for cervical conditions or a 3-month trial of different conservative treatments per ASRA consensus; document prior conservative therapies and durations.

Diagnostic block and sequencing guidance: Diagnostic medial branch or facet joint blocks may be used to identify facet-mediated pain and to select patients for radiofrequency denervation; societies describe single or dual block paradigms with varying threshold guidance.

Document onset and duration of relief consistent with the local anesthetic used; societies reference ≥50% as a positive block and ≥80% relief for confirmatory/dual blocks in some recommendations.

Therapeutic injections evidence stance: Therapeutic facet joint and medial branch injections have mixed, generally low-quality evidence for long-term efficacy; randomized trial data are limited and results are variable.

Guideline evidence statements

Evidence and guideline statements relevant to coverage decisions

Therapeutic medial branch blocks evidence: Therapeutic medial branch blocks are performed in the same manner as diagnostic blocks but current evidence does not support their use as a therapeutic intervention.

NASS and other guideline statements note insufficient evidence (multiple recommendations graded I) for many facet procedures; clinicians should weigh risks and benefits, particularly for thoracic procedures where literature is sparse.

NASS guidance highlights: NASS identifies multiple items rated Grade I (insufficient evidence) including use of pain reproduction as predictor, the use of a 50% relief threshold, and steroid injections; NASS includes a Grade B statement that intra-articular steroid provides no clinically meaningful improvement at 6 months when selected by a single diagnostic injection response.50% pain relief referenced

Guideline stances inform clinical decision-making and coverage considerations but do not alone determine coverage.

WFNS diagnostic utility statement:

Facet Joint Injections and Medial Branch Blocks performed under ultrasound guidance are considered unproven and not medically necessary due to insufficient evidence of efficacy.

There is no peer-reviewed evidence demonstrating overall health benefit of ultrasound guidance compared with fluoroscopy or CT for spinal facet procedures; clinical guidelines do not recommend ultrasound as the preferred imaging modality. Systematic reviews note higher rates of incorrect needle placement with ultrasound-confirmed by fluoroscopy/CT and significant study limitations, so ultrasound guidance is not supported as superior to fluoroscopy/CT and is not recommended.

Current evidence does not support the use of therapeutic medial branch blocks as a long‑term therapeutic intervention; they are performed like diagnostic blocks but data are insufficient to establish effectiveness for sustained pain management.

Therapeutic facet joint and medial branch block injections at the cervical, thoracic, and lumbar levels are described as unproven and not medically necessary because evidence of efficacy and safety is limited and of low quality.

Routine use of therapeutic medial branch blocks and routine intra-articular facet injections for chronic nonspecific axial pain is not supported by current evidence; guideline panels generally advise against routine therapeutic injections for this indication.

Use of therapeutic medial branch blocks for long-term pain management is not supported by the literature and is therefore considered an unsupported therapeutic strategy.

Coding and Diagnostics

Applicable procedure CPT/HCPCS 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.
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).
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 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.

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Procedures/Devices/Drugs regulatory notemixed

No codes listed

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

ThresholdPositive diagnostic block defined as ≥50% pain relief for at least the expected minimum duration of the local anesthetic

Measured outcomePatient-reported pain reduction (percentage) sustained for duration consistent with chosen anesthetic

Applicable proceduresApplies to facet joint injections and medial branch (facet nerve) blocks when performed diagnostically

inv-15: Diagnostic response threshold mentioned — 50% reduction in pain after medial branch blockade referenced in guidelines

Guideline-referenced thresholdAt least a 50% reduction in pain after medial branch blockade is considered a positive prognostic/diagnostic response in ASRA guidance

Provider Actions and Documentation

Prior Authorization

Use InterQual® and verify state/contractual requirements

Before using this policy, verify applicable federal, state (Ohio Administrative Code [OAC]), and contractual benefit requirements, as those terms govern coverage and may differ from this standard policy. UnitedHealthcare uses InterQual® as the primary medical/surgical criteria source for coverage determinations; if InterQual® does not have applicable criteria, UnitedHealthcare may use other approved Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines. This policy is informational and does not constitute medical advice.

Check federal, state (OAC), and contractual benefit language before applying policy
Use InterQual® criteria as primary medical/surgical basis for determinations
If InterQual® is not applicable, alternative UnitedHealthcare guidelines approved by the Ohio Department for Medicaid Services may be used

Documentation Required

Medical records requirements

The patient's medical record must contain legible documentation that fully supports the medical necessity of the requested services. Documentation should include relevant history, physical examination findings, and results of pertinent diagnostic studies or procedures, and must be made available upon request. Benefit coverage is determined by federal, state, or contractual requirements and applicable law; documentation does not guarantee coverage.

Background

Facet joint injections and medial branch blocks involve injection of a local anesthetic, with or without corticosteroid, into the facet joint capsule or along the medial branch nerves to diagnose or treat suspected facet-mediated spinal pain. Imaging guidance (typically fluoroscopy or CT) and documentation of the magnitude and duration of pain relief are used to interpret diagnostic response and to guide further interventions.

Definitions

inv-29: Facet Joint Injections — Injection of local anesthetic and/or corticosteroid into the facet joint capsule; diagnostic test positive when ≥50% relief.

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

Diagnostic positivityConsidered positive when there is at least 50% relief of pain sustained for the expected minimum duration of the local anesthetic

PurposeUsed diagnostically to identify facet joint–mediated pain and less predictive than medial branch blocks

inv-30: Medial Branch Block / Facet Nerve Block — Injection of local anesthetic and/or corticosteroid along nerves supplying facet joints; diagnostic use described.

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

Diagnostic use

Conservative Treatment Requirements

Documented trial of conservative management prior to interventions

Documented trial of conservative management prior to interventions is required:

Conservative management documented: Medical record documents a trial of appropriate conservative therapies (examples: medications, physical therapy, exercise, integrative treatments) prior to facet joint or medial branch interventions.

Examples of recommended durations include at least a 6-week trial for cervical conditions and a 3-month trial of different conservative treatments per ASRA consensus; InterQual criteria also require failure of conservative therapy before consideration.

Frequency and Procedural Limits

inv-37: Imaging-guided procedures referenced — policy references imaging-guided procedures with fluoroscopy or CT and makes ultrasound-guided procedures not medically necessary.

Imaging guidance requirementFacet joint and medial branch procedures should be performed with image guidance (fluoroscopy or CT preferred)

Ultrasound stanceUltrasound-guided facet/medial branch injections are considered unproven and not medically necessary in this policy

Operator considerationsUltrasound guidance is operator-dependent and evidence does not show it is superior to fluoroscopy/CT

inv-38: Cervical medial branch and interarticular injections — guidance specifies small injectate volumes (≤0.3 mL for cervical medial branch; total ≤1 mL for interarticular) but does not set numeric frequency limits.

Cervical medial branch injectate volumeFor cervical medial branch block, injectate volumes ≤0.3 mL are specified (slightly higher volumes may be considered if necessary)

Imaging Guidance Requirements

Billing Rule

Use fluoroscopy or CT guidance for facet/medial branch injections

For facet joint and medial branch injections, use fluoroscopy or CT guidance per the policy; ultrasound guidance is not supported for these procedures.

Policy lists image-guided codes for fluoroscopy/CT (64490–64495) and indicates imaging guidance is used for these injections.
Ultrasound-guided codes are listed but the policy deems ultrasound guidance unproven/not medically necessary.

Note

Prefer fluoroscopy/CT; ultrasound is operator-dependent and not superior

Fluoroscopy or CT is generally preferred for facet joint and medial branch injections; the policy notes ultrasound is operator-dependent and not shown to be superior to fluoroscopy/CT.

ASRA and other guidance note ultrasound is operator-dependent and evidence does not demonstrate superiority.

Not Covered

Not covered under this policy are facet joint/medial branch injections performed under ultrasound guidance and therapeutic facet joint/medial branch injections at cervical, thoracic, and lumbar levels, both of which are described as unproven or lacking sufficient evidence to be medically necessary.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS178OH.D

Change TypeDocumentation and related-policy updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity, including history, exam, and pertinent diagnostic results.

SourceLink

On This Page

Systematic reviews report short-term improvements up to ~3 months in some studies but methodological limitations and inconsistent findings lead several societies to recommend caution or not to support routine therapeutic use.

The World Federation of Neurosurgical Societies (WFNS) states that facet joint injections provide a useful diagnostic tool for low back pain.

Supports diagnostic utility of facet injections.

ContextASRA and guideline documents note 50% as a commonly referenced cutoff but discuss higher thresholds (e.g., 80%) for confirmatory testing

UseThreshold used to identify potential candidates for further interventions such as radiofrequency neurotomy when combined with clinical evaluation

Include relevant medical history, exam findings, and diagnostic test results
Maintain legible records and make available upon request
Documentation may be required for coverage review but does not guarantee payment

Denial Risk

Documentation-driven denials

Medical records that do not fully support the medical necessity of the procedure may result in claim denial or requirement for additional review. Providers should ensure documentation is complete and addresses all policy criteria to reduce the risk of documentation-driven denials.

Incomplete or missing documentation may lead to denial or requests for more information
Ensure records explicitly document how criteria are met (e.g., conservative therapy trials, diagnostic block response)

Documentation Required

Conservative therapy documentation

Conservative therapy should be attempted and documented prior to facet interventions. Examples include medications (NSAIDs, antidepressants), physical therapy or exercise programs, integrative treatments (acupuncture, spinal manipulation), weight management, sleep hygiene, and other noninvasive measures. Documentation should specify the therapies used, duration (e.g., at least a 6-week trial or 3 months for some neck pain scenarios as noted by specialty guidance), and patient response.

Document types of conservative therapy tried and objective duration (e.g., ≥6 weeks; 3 months for some neck pain scenarios)
Record concomitant use of conservative measures when prognostic blocks are performed
Lack of documented conservative therapy may lead to denial or additional review

Denial Risk

Ultrasound guidance exclusion

Facet joint and medial branch injections performed under ultrasound guidance are considered unproven and not medically necessary due to insufficient evidence of efficacy. Refer to the applicable CPT/HCPCS codes listed in the policy for image-guided procedures and note that ultrasound-guided facet procedures are excluded.

Ultrasound-guided facet/medial branch injections are unproven and not medically necessary
Relevant ultrasound-specific procedure codes (e.g., 0213T–0218T) are included in the policy for reference but do not imply coverage

Note

Use of diagnostic block to guide RFA

Diagnostic (prognostic) blocks may be used to select patients for radiofrequency ablation (RFA); they are prognostic tests rather than therapeutic interventions. Document the magnitude and duration of pain relief following diagnostic blocks (for example, a confirmatory block with ≥80% relief and an onset/duration consistent with the anesthetic used).

Use diagnostic blocks to guide selection for RFA; they are prognostic, not therapeutic
Document onset and duration of relief consistent with the anesthetic used
For confirmatory (second) blocks, document ≥80% relief when required

Note

Diagnostic sequencing guidance

Society guidance favors conservative treatment trials and specific diagnostic sequencing prior to advanced interventions. Recommendations include performing a trial of conservative management (commonly 6 weeks to 3 months depending on anatomical region and clinical scenario), using single diagnostic blocks in many cases, and recognizing that dual (confirmatory) blocks may improve predictive value for subsequent medial branch RFA but are not universally required. When dual blocks are used, a second confirmatory injection is indicated only if the first produced ≥80% relief and the timing/duration of relief matches the anesthetic.

Perform conservative therapy trial before prognostic blocks (typical guidance: ≥6 weeks; e.g., 3 months for some neck pain)
Single diagnostic block is commonly recommended; dual blocks may be used to confirm diagnosis when indicated
If first block yields ≥80% relief and timing is appropriate, a confirmatory block can be performed to verify source

Documentation Required

Document diagnostic block response

When diagnostic medial branch blocks are used, document the response thoroughly: the percent pain reduction, onset and minimum duration of relief consistent with the agent used, and whether relief exceeded thresholds used to indicate confirmatory testing (e.g., ≥80% for a second confirmatory block). If relief is <80%, document consideration of additional levels or alternative diagnoses.

Record percent pain reduction and duration of relief after each diagnostic block
For confirmatory blocks, document ≥80% relief and timing consistent with anesthetic
If relief is inadequate, document rationale for additional testing or different target levels

Documentation Required

Medical records documentation requirements

Providers should ensure medical records contain legible, comprehensive documentation that supports medical necessity, including history, physical exam, diagnostic imaging or studies, conservative therapy attempts and durations, procedural details, and post-procedure responses. Failure to include these elements may lead to review delays or denials.

Include history, physical exam, imaging/studies, conservative therapy trials, procedural details, and response documentation
Maintain legible records and be prepared to provide them upon request to support medical necessity

Note

Provider action placeholder: ensure all required documentation and preauthorization steps are completed per the plan and state-specific rules before submitting claims.

Used to target nerves that innervate facet joints to help identify facet-mediated pain

TechniquePerformed with imaging guidance (fluoroscopy or CT preferred) and local skin anesthesia; may require sedation in some individuals

inv-31: Dual (confirmatory) medial branch block — Two injections performed at the same location on separate occasions, with the second confirmatory injection indicated when the first provides temporary relief.

DefinitionTwo injections performed at the same location on separate occasions to confirm diagnosis

Indication for second blockA second (confirmatory) injection is indicated only if the first produces ≥80% relief and onset/duration match the anesthetic used

Alternative useA second injection may be performed at a different level if initial relief is <80% and a different joint is suspected

inv-32: Positive prognostic block — A reduction in pain considered sufficient to predict response to neurotomy or further intervention; thresholds discussed include >50% and higher values.

PurposeA prognostic block demonstrates a reduction in pain sufficient to predict response to neurotomy or further intervention

Thresholds discussedGuidelines reference thresholds >50% and higher values (e.g., ≥80% for confirmatory blocks) depending on society recommendations

DocumentationOnset and duration of relief should be consistent with the anesthetic used and recorded to support prognostic value

inv-33: Therapeutic Medial Branch Blocks — injections intended to achieve long-term pain management performed in the same manner as diagnostic medial branch blocks but used therapeutically.

DefinitionInjections performed in the same manner as diagnostic medial branch blocks but intended for long-term pain management

Evidence stanceCurrent evidence does not support therapeutic medial branch blocks as an effective long-term therapeutic intervention

Guideline recommendationsSeveral societies recommend against routine therapeutic medial branch injections due to insufficient evidence

Cervical interarticular volumeFor cervical interarticular facet joint injection, total volume should not exceed 1 mL (including contrast) to avoid capsular rupture and enhance specificity

Frequency limitsGuidance specifies small injectate volumes but does not set numeric frequency limits for cervical injections

inv-39: Facet joint and medial branch block injections — no explicit numeric frequency limits found in source chunks.

Frequency limits absenceNo explicit numeric frequency limits for facet joint or medial branch block injections are specified in the policy or referenced guideline chunks

Practice implicationDecisions on timing/frequency should follow InterQual guidance and clinical judgment, and documentation of conservative trials and responses is expected

MonitoringRecord magnitude and duration of pain relief to support decisions about repeat procedures

When performing cervical medial branch blocks, fluoroscopy (or ultrasound per ASRA guidance) may be used, but overall policy preference remains fluoroscopy/CT.

Billing Rule

Obtain CT or MRI before atlanto‑occipital/atlanto‑axial injections

For atlanto‑occipital and atlanto‑axial joint injections, obtain preprocedural advanced imaging (CT or MRI) to ascertain pathology and guide needle trajectory as recommended.

ASRA guidance recommends CT or MRI prior to atlanto‑occipital and atlanto‑axial injections.
Document imaging used to plan the procedure in the medical record.

Documentation Required

Document diagnostic injection response; imaging modality guidance not specified

When documenting diagnostic medial branch or facet joint injections, record the patient response, including percentage pain relief and timing; the policy discusses diagnostic response thresholds but does not specify an imaging requirement for these diagnostic injections.

Guidelines reference response thresholds (50% and 80% in different contexts) for diagnostic utility.
Ensure procedural and outcome details are included in the record to support diagnostic claims.