UnitedHealthcare facet/medial-branch blocks Coverage Update

Coverage summary

This New Jersey UnitedHealthcare policy (Policy CS178NJ.E) effective May 1, 2025 and last reviewed February 20, 2025 provides state-specific coverage criteria for diagnostic and therapeutic Facet Joint Injections (FJI) and Medial Branch (Facet Nerve) Blocks. The coverage stance is mixed: diagnostic injections performed to identify facet-mediated pain can be medically necessary when specific criteria are met, while many therapeutic uses and certain circumstances (including ultrasound guidance as performed in listed situations) are considered unproven/not medically necessary due to insufficient evidence. Key threshold summaries: initial diagnostic block requires failure of conservative care and pain ≥ 3/10 after ≥ 4 weeks; diagnostic block positivity is defined as ≥ 50% relief for at least the expected anesthetic duration, and guideline-based confirmatory testing may require ≥ 80% relief for a dual/confirmatory block.

Quick facts / Policy thresholds

Pain severity after conservative care>= 3 on 1-10 pain scale after minimum 4 weeks of conservative care

Diagnostic block positive>= 50% pain relief for at least the expected minimum duration of the local anesthetic

Medial branch block volume limitsLumbar MBB: < 0.5 mL total volume; Cervical MBB: <= 0.3 mL recommended

Confirmatory relief thresholds>= 80% relief required for confirmatory (dual) diagnostic block per guideline; policy recognizes >=50% as diagnostic positive but uses 80% for confirmatory selection for RFA

Note state-specific NJ scopePolicy applies to New Jersey Medicaid (state-specific); ultrasound-guided CPT codes (0213T–0218T) are not on NJ Medicaid fee schedule and may not be covered

Medical necessity — diagnostic and confirmatory blocks

Initial diagnostic Facet Joint Injection/Medial Branch Block (Medically Necessary)

Covered when ALL of the following are met:

ALL of the following

Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation).
Clinically significant improvement has not occurred (the pain remains at a 3 or more on a 1-10 pain scale) after a minimum of four weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy).
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).
The spinal motion segment is not fused.

Unproven and not medically necessary indications

Unproven / Not Medically Necessary

The following are unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Facet Joint/Medial Branch Block if radiofrequency ablation procedure not considered as treatment option at the requested level(s).
Facet Joint/Medial Branch Block for treating spinal pain after diagnostic injections have been completed (i.e., therapeutic use after diagnostics).

Related Non-Covered / Unproven Indications (additional statements)

The policy also states the following are considered unproven and not medically necessary:

ANY of the following

Procedure and diagnosis codes

Procedure codes (reference list; some not on NJ Medicaid fee schedule)CPT|HCPCS|mixed

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.

1–10 of 12

1/2

Diagnosis codes (examples provided)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.

1–10 of 15

1/2

Procedure/Intervention Codes (policy discusses facet joint and medial branch block procedures)mixed

No codes listed

Provider actions, documentation, and billing guidance

Prior Authorization

Radiofrequency denervation consideration

When requesting authorization or documenting medical necessity for diagnostic facet/medial branch blocks, indicate that radiofrequency joint denervation/ablation is being considered as a treatment option for the targeted level(s). Include this consideration in the prior authorization/clinical justification so the diagnostic block is evaluated as part of a pathway toward potential RFA.

Documentation Required

Document conservative therapy failure and pain score

Document that the patient underwent a minimum of four weeks of conservative care without clinically significant improvement and that the index pain remains at least 3/10 on a 1–10 pain scale prior to performing an initial diagnostic facet joint injection or medial branch block.

Documentation Required

Background and evidence summary

Facet joint injections and medial branch blocks are used both diagnostically and (less consistently) therapeutically for suspected facetogenic spinal pain; injections are performed with imaging guidance and local anesthetic with or without corticosteroid. Evidence is stronger for diagnostic utility—these injections can help identify patients likely to benefit from radiofrequency denervation—while therapeutic benefit for long-term pain control is limited and of low/variable quality. The policy notes limited high-quality evidence for thoracic spine injections and emphasizes imaging guidance (fluoroscopy or CT) as standard; ultrasound guidance lacks high-quality evidence of overall health benefit versus fluoroscopy/CT and systematic reviews report concerns about higher rates of incorrect needle placement with ultrasound-confirmed comparisons.

Citation	Key point
Cohen et al. (2018 RCT)	Diagnostic facet/medial branch blocks are not therapeutic but may predict response to radiofrequency ablation; similar short-term pain reduction versus placebo; higher responder rates when used to select patients for RFA.
Manchikanti et al. (systematic reviews)	Evidence supports diagnostic validity of lumbar medial branch blocks (level I evidence for diagnostic validity with substantial pain relief criteria); therapeutic evidence is variable for long-term improvement with radiofrequency neurotomy.
Hayes (2024 assessment)	Low-quality evidence suggests lumbar facet joint injections may provide pain relief up to 3–6 months; insufficient evidence for thoracic/cervical regions and uncertainty due to lack of placebo-controlled trials.
Ultrasound guidance systematic reviews	No clear superiority of ultrasound guidance over fluoroscopy/CT; mixed results and concerns about higher risk of incorrect needle placement with ultrasound compared with fluoroscopy/CT.
NASS (2016/2020)	Recommends dual diagnostic medial branch blocks to confirm facet-mediated pain; second confirmatory injection indicated only if first produces ≥80% relief with appropriate onset/duration; insufficient evidence for many therapeutic uses.
VA/DoD (2022 guideline)	Suggests against injection of corticosteroids for intra-articular facet joint injections and against therapeutic medial branch blocks with steroid.

Acute Low Back Pain: Low back pain present up to six weeks; early acute <2 weeks, late acute 2–6 weeks.

Conservative Therapy: Combination of medication (e.g., NSAIDs), physical therapy, spinal manipulation, cognitive behavioral therapy (CBT), or other individualized interventions.

Facet Joint Injections (FJIs): Injection of local anesthetic and/or corticosteroid into the facet joint capsule; diagnostic considered positive when ≥50% pain relief for at least the expected anesthetic duration.

Facet Nerve Block / Medial Branch Block: Injection of local anesthetic and/or corticosteroid along nerves supplying facet joints; diagnostic considered positive when ≥50% pain relief for at least the expected anesthetic duration.

Radiculopathy: Pain radiating from the spine along a spinal nerve root, often following a dermatomal pattern.

Dual diagnostic medial branch blocks: Two medial branch blocks performed in the same location(s) on two separate occasions to confirm facet-mediated pain.

Guideline positions on therapeutic medial branch blocks

Therapeutic Medial Branch Blocks (Guideline statements)

NASS and other guideline-based positions summarized:

ANY of the following

Therapeutic medial branch blocks are intended for long-term pain management but current evidence does not support their use as a therapeutic intervention.
There is insufficient evidence to make recommendations for or against multiple practice items including: use of patient-reported reproduction of pain during injection as predictor of response to dual diagnostic blocks; use of intra-articular steroid injection providing clinically meaningful improvement at 6 months when selection was based on single diagnostic injection with 50% relief; use of radiofrequency neurotomy or periarticular phenol injections under those selection criteria; use of steroid injections for chronic back pain with exam suggestive of facet-mediated pain; uncontrolled medial branch blocks vs pericapsular blocks for diagnosis; and the use of 50% reduction in pain following medial branch blockade for diagnosis. (NASS 2020 - Grades I or B as specified)

Thoracic Facet/Intra-articular Injections

Guideline note

Revision history

2025-05-01material_change_effectiveLatest

Effective 05/01/2025 — Added language clarifying that the listed circumstances are unproven and are considered not medically necessary for Facet Joint Injections/Medial Branch Blocks due to insufficient evidence of efficacy; previous policy version CS178NJ.D archived.

2025-05-01references_updated

References and Clinical Evidence sections updated through 2025 to reflect current information (systematic reviews, guideline publications) as noted in policy history.

OpenPayer

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

Coverage summary

Medical necessity — diagnostic and confirmatory blocks

Unproven and not medically necessary indications

Procedure and diagnosis codes

Provider actions, documentation, and billing guidance

Background and evidence summary

Guideline positions on therapeutic medial branch blocks

Revision history