UnitedHealthcare Facet Joint Injection Coverage Update

Coverage Criteria for Facet Joint and Medial Branch Injections

inv-01: Initial diagnostic Facet Joint Injection/Medial Branch Block

Covered when ALL of the following are met:

Initial diagnostic block: Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation); AND clinically significant improvement has not occurred (pain remains ≥3/10) after a minimum of four weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy); AND clinical findings and imaging studies suggest no other cause of the pain (e.g., spinal stenosis with neurogenic claudication, disc herniation with radicular pain, infection, tumor, fracture, pain related to prior surgery); AND the spinal motion segment is not fused; AND a radiofrequency joint denervation/ablation procedure is being considered

From policy: initial diagnostic Facet Joint Injection/Medial Branch Block criteria

inv-02: Second diagnostic/confirmatory block

Covered when ALL of the following are met:

Second confirmatory block: Administered at the same level and side as the initial block; AND the initial diagnostic block produced a positive response demonstrated by at least the expected minimum duration of the effect of the local anesthetic AND functional improvement specific to the previously limited physical functions; AND a radiofrequency joint denervation/ablation procedure is being considered

Second block to confirm validity prior to RFA; NASS/other societies specify dual-block confirmation rules

inv-03: Therapeutic injections

Covered when ALL of the following are met:

Therapeutic facet joint/medial branch block: Performed after two facet injections/medial branch blocks at the same level and same side (treated as therapeutic rather than diagnostic); AND intended for treatment of chronic spinal pain per policy guidance

Policy treats two injections at same level/side as therapeutic

inv-04: Society guideline criteria and technical recommendations

Society guidelines summarize indications, diagnostic thresholds, and conservative therapy requirements for facet interventions.

Conservative therapy before interventions: Recommend trial of conservative therapy prior to facet interventions (examples: medications, physical therapies, integrative treatments); ASRA/Cohen et al. recommend a 3-month trial for lumbar interventions and at least 6 weeks for cervical with concomitant conservative measures.duration varies by guideline (eg, 3 months lumbar / ≥6 weeks cervical)

Referenced in ASRA consensus and multisociety guidance

Diagnostic block success criteria: Society-recommended cutoffs vary: ASRA suggests >50% reduction may be considered positive; AANS/CNS and NASS recommend ≥80% improvement for confirming lumbar facet-mediated pain when using dual (double-injection) technique.>=50% or >=80% depending on guideline

NASS specifies ≥80% for confirmatory dual blocks

Technique and volume recommendations:

inv-05: Ultrasound guidance evidence

Findings on ultrasound-guided injections compared with fluoroscopy/CT guidance.

Ultrasound guidance outcomes: Systematic reviews and a meta-analysis report an increased risk difference of incorrect needle placement for ultrasound-guided medial branch blocks (~11%) and facet joint injections (~13%) when confirmed by fluoroscopy/CT; smaller clinical series and a limited meta-analysis report feasibility, reduced radiation exposure, and no significant differences in pain/function in some small trials, but overall evidence certainty is low to very low.

Evidence limited by heterogeneity, small samples, and operator skill variability

inv-06: Not Medically Necessary (updated)

Policy revision indicates certain listed circumstances are considered unproven and not medically necessary.

Unproven indications marked NMN: Listed circumstances for facet joint injections/medial branch blocks are designated unproven and not medically necessary due to insufficient evidence of efficacy (examples include diagnostic/confirmatory blocks when radiofrequency ablation is not being considered, and other listed scenarios updated in this revision).

See full policy and revision history for the specific listed circumstances and rationale

Medial branch injections performed for diagnostic purposes in excess of four (4) injections in a calendar year are excluded from coverage per TennCare policy. Providers must follow the TennCare Medicaid Chapter 1200-13-13-.10 exclusions when submitting claims for diagnostic medial branch injections that would exceed this annual limit.

For therapeutic Facet Joint and Medial Branch Block injections at the cervical, thoracic, and lumbar levels, refer to the TennCare Medicaid Chapter 1200-13-13-.10: Exclusions. The policy notes related state-specific exclusions and references the TennCare chapter for additional coverage rules and exceptions.

Major society guidance cautions about routine corticosteroid use with facet procedures. The ACOEM 2021 guidance lists therapeutic intra-articular facet joint injections as Not Recommended for acute and subacute low back pain and raises concerns about repeat use. The VA/DoD 2022 guidance similarly recommends against injecting corticosteroids for intra-articular facet joint injections and for therapeutic medial branch blocks.

Policy revision effective 06/01/2025: the previous policy version was archived and the coverage rationale was updated to clarify that certain listed circumstances are designated as unproven and not medically necessary for Facet Joint Injections and Medial Branch Blocks due to insufficient evidence of efficacy. See the policy history for the archived version reference.

Facet joint injections and medial branch blocks listed as diagnostic or confirmatory when radiofrequency ablation (RFA) is not being considered are explicitly designated as unproven and not medically necessary. Claims submitted for blocks performed for diagnostic confirmation when RFA is not an intended treatment option at the requested level(s) may be subject to denial under the policy.

The policy notes that use of ultrasound guidance for facet joint injections and medial branch blocks is performed under listed CPTs but is not recommended by some clinical guidance and lacks evidence of overall health benefit compared with fluoroscopy or CT. Providers should be aware that ultrasound-guided procedures may be scrutinized and require supporting documentation of technique and appropriateness.

The policy explicitly states that the circumstances listed in the Not Medically Necessary section are considered unproven and not medically necessary for Facet Joint Injections and Medial Branch Blocks due to insufficient evidence of efficacy. This clarification was added in the 06/01/2025 revision and applies to items such as blocks performed when RFA is not being considered, routine therapeutic injections without demonstrated benefit, and other specified exclusions.

Applicable Codes and Coding Guidance

Applicable 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 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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Example ICD-10 Codes listedICD-10

M47.812	Spondylosis without myelopathy or radiculopathy, cervical region.
M47.816	Spondylosis without myelopathy or radiculopathy, lumbar region.
M47.9	Spondylosis, unspecified.

Diagnostic block positive threshold — ≥ 50% pain relief

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

ContextDiagnostic FJI/MBB considered positive when pain reduction meets threshold during expected anesthetic effect

Documentation requiredRecord percent pain relief and duration consistent with anesthetic used

Diagnostic relief thresholds — >=50% (ASRA/Cervical) and >=80% (AANS/CNS and NASS)

ASRA / Cervical guidance>= 50% reduction in pain may be considered a positive block (ASRA); cervical prognostic block: >=50% positive

AANS/CNS and NASS (dual-block confirmation)

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

State Medicaid Applicability

This policy applies to Tennessee Medicaid/CoverKids. Follow state Medicaid prior authorization and coverage rules; refer to TennCare Medicaid, Chapter 1200-13-13-.10: Exclusions for details and limits (for example, diagnostic medial branch injections in excess of four injections in a calendar year are excluded).

Applies to Tennessee Medicaid and CoverKids
Follow TennCare Medicaid prior authorization, exclusions, and coverage rules

Documentation Required

Confirmatory Blocks and Documentation

Dual medial branch/confirmatory blocks are recommended as confirmatory diagnostic steps prior to radiofrequency ablation (RFA). A second confirmatory injection is indicated when the first block produces substantial relief (see criteria below) and the timing/duration of relief matches the local anesthetic used.

Perform dual blocks in the same location(s) on separate occasions to confirm diagnosis prior to RFA.

Conservative Treatment and Prior Therapy Requirements

inv-38: Required prior to diagnostic injection

Required prior to performing an initial diagnostic injection:

Minimum conservative therapy before diagnostic injection: A minimum of four weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy) with persistent pain severity ≥3/10 must be documented prior to an initial diagnostic facet joint injection/medial branch block.>= 4 weeks

From policy: conservative care requirement before diagnostic injection

inv-39: Document prior conservative therapy and response before prognostic blocks

Document prior conservative therapy and response before proceeding with prognostic (confirmatory) blocks per guideline timelines:

Guideline timelines for conservative therapy: ASRA/Cohen et al. recommend a 3-month trial of different conservative treatments before lumbar facet interventions; for cervical prognostic blocks, a minimum trial of at least 6 weeks is recommended (concomitant conservative measures should accompany prognostic blocks).

Procedural Frequency Limits

Diagnostic medial branch injections — limited to 4 per calendar year

Annual limitDiagnostic medial branch injections limited to 4 per calendar year; injections in excess are excluded from coverage

ReferenceTennCare Medicaid, Chapter 1200-13-13-.10 cited for exclusions

ImplicationClaims for diagnostic medial branch injections beyond 4/year may be denied

Medial branch blocks — Second confirmatory block when indicated

Dual-block paradigmA second confirmatory medial branch block is indicated when the first produces >= 80% relief and onset/duration consistent with the agent used

Alternative useIf initial relief <80%, a second block may be performed at a different/additional level if clinically suspected

Imaging and Guidance Requirements

Billing Rule

Use fluoroscopy or CT guidance (preferred); ultrasound listed but not guideline‑recommended

Fluoroscopy or CT image guidance is preferred for facet joint and medial branch injections; ultrasound is listed in CPTs as acceptable but is not recommended by clinical guidelines and lacks evidence of overall health benefit compared with fluoroscopy/CT.

When billing, use the image‑guidance modality consistent with clinical guidelines and document reason if ultrasound is used.

Documentation Required

CT or MRI recommended before AO/AA injections

For atlanto‑occipital and atlanto‑axial (AO/AA) joint injections, obtain advanced imaging with CT or MRI prior to the procedure to guide needle trajectory and ascertain pathology.

Definitions

Facet Joint Injections (FJIs) — definition and diagnostic positivity threshold

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

Diagnostic positivityConsidered positive when >= 50% relief for at least the expected duration of the local anesthetic

Comparative utilityFacet joint injections can be diagnostic but are less predictive than medial branch blocks for RFA outcomes (per ASRA)

Medial Branch Block / Facet Nerve Block — definition and diagnostic positivity threshold

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

Diagnostic positivityDiagnostic medial branch block considered positive when >= 50% relief for at least the expected anesthetic duration

Background

Facet joint injections and medial branch blocks are used to diagnose and sometimes treat facetogenic spinal pain. Diagnostic medial branch blocks are covered when criteria are met, including pain provocation with facet loading maneuvers, persistent pain (≥3/10) after a minimum of four weeks of conservative care, exclusion of other causes by clinical and imaging assessment, an unfused motion segment, and when a radiofrequency joint denervation/ablation procedure is being considered. A second confirmatory block at the same level and side is covered when the initial block produced a positive response for at least the expected anesthetic duration with demonstrable functional improvement and RFA remains a treatment option.

Not Covered / Exclusions

Not covered: Diagnostic medial branch injections in excess of four (4) injections per calendar year; facet joint or medial branch blocks performed when radiofrequency ablation is not being considered at the requested level(s); routine intra-articular therapeutic facet injections and corticosteroid use in contexts discouraged by specialty guidance; and other specific circumstances that have been marked unproven and not medically necessary in the most recent policy revision. Providers should consult the TennCare exclusion language and the policy history for full details.

OpenPayer

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

Coverage Criteria for Facet Joint and Medial Branch Injections

Applicable Codes and Coding Guidance

Provider Actions, Documentation, and Prior Authorization

Conservative Treatment and Prior Therapy Requirements

Procedural Frequency Limits

Imaging and Guidance Requirements

Definitions

Background

Not Covered / Exclusions