This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Facet Blocks for Treatment of Back Pain

Facet Blocks for Treatment of Back Pain

 

DESCRIPTION

 The facet joints of the vertebrae (zygapophyseal joints) have been implicated as possible sources of low back pain. The existence of a spinal facet joint syndrome has not been established. The purported key indication of facet syndrome is a positive response to a diagnostic block of the joint or nerves innervating the joint using local anesthetics. For patients with positive diagnostic blocks, treatments for low back pain due to facet joint syndrome include the injection of local anesthetics, corticosteroids and phenol and percutaneous radiofrequency facet denervation.

 

POLICY

 This procedure can be performed when facet joint pain is suspected in patients with back pain, without a strong radicular component, and without associated neurologic deficit although the pain is aggravated by hyperextension of the spine. This type of block is used for diagnostic purposes to answer specific questions resulting from a careful evaluation of a patient's pain problem and in some situations is therapeutic in itself.

Two (2) sessions per level per calendar year [maximum of three (3) facet blocks per session] using local anesthetic, corticosteroid or phenol are considered medically necessary. 

All facet blocks must be done utilizing fluoroscopy for injection.

Hypertonic saline or iced saline are not neurolytic agents in the true sense and their use for nerve/facet block is not medically necessary.

This type block can be utilized where there seems to be a discrepancy between known pathology and complaints or findings (e.g., a disc lesion at one level and pain at another).

This type block can be used, along with other type chronic pain treatment for other lesions, to assess the role and contribution of the facet syndrome.

Destruction of the paravertebral facet joint nerve by thermal  (non-pulsed only) radiofrequency is not medically necessary, except in the extremely rare circumstance as a last resort. Under any and all circumstances, thermal (non-pulsed) radiofrequency destruction will only be allowed at the same level one (1) time per calendar year. 

Under any and all circumstances, pulsed radiofrequency or chemical destruction is not medically necessary. 

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 2/1999: Approved by Medical Policy Advisory Committee (MPAC); A lifetime maximum of 2 facet blocks (2 dates of service) with intra-articular injection using local anesthetic, corticosteroid or phenol are considered medically necessary for relief of facet-related low back pain; A re-injury is eligible for up to 2 additional facet blocks, but must be prior authorized; Multiple level blocks may be billed one time only, regardless of the number of additional levels injected. The -50 and -51 modifiers may not be used.

11/2000: Revised by MPAC, “Any injection must be accompanied by concurrent physical therapy” added Description section, “A facet block with intra-articular injection using local anesthetic, corticosteroid or phenol is considered medically necessary for relief of facet-related low back pain” added Policy section, “A lifetime maximum of 2 facet blocks (2 dates of service) with intra-articular injection using local anesthetic, corticosteroid or phenol are considered medically necessary for relief of facet-related low back pain” deleted

3/15/2001 CPT codes effective 1/1/2000 added to "Policy Guidelines" Effective 12/31/1999 CPT code 64442 will be deleted and replaced with CPT code 64475 after 1/1/2000.  Effective 12/31/1999 CPT code 64443 will be deleted and replaced with CPT code 64476 after 1/1/2000. Effective 12/31/1999 CPT code 76000 should not be used.  Replaced CPT code 76000 with CPT code 76005 after 1/1/2000

6/19/2001: Code Reference section reviewed, ICD-9 procedure code 04.81 added covered codes, ICD-9 diagnosis code 724.2 added covered codes

7/23/2001: CPT codes 64442, 64443 deleted from the Code reference section

2/1/2002: Appeal statement “All medical policies are written for the majority of people with a given condition.  Each policy is based on medical science.  For many of our medical policies, each individual’s unique clinical circumstances may be considered in light of current scientific literature.  Physicians may send relevant clinical information for consideration of an individual patient.” deleted from Policy Exception section

3/5/2002: Prior authorization deleted

4/18/2002: Modifier 51 removed from multiple level blocks statement. CPT code 64472 and 64476 moved to non-covered. Type of Service and Place of Service deleted.

10/4/2002: “Any injection must be accompanied by concurrent physical therapy.” moved to Policy section, “Only one facet joint block at each level (e.g., C3, C5, L1, L2, T1, T2, or S1) is medically necessary. Multiple blocks at the same level are not medically necessary. No allowance will be made for multiple injections or bilateral injections at the same level of the spine” added Policy section, “Multiple level blocks may be billed one time only, regardless of the number of additional levels injected. The -50 modifier may not be used." deleted Policy section, References to bundling “There are two facet joints in a single level facet joint block. CPT code 64442 should be used to report the injection of the right and left facet joints of a single vertebral segment. In a two-level block, there may be four facet joints blocked (left and right at two levels). For this service, report codes 64442 and 64443. CPT 64443 may be billed one time only, regardless of the number of additional levels injected. This one-needle technique is considered inherently bilateral and should be reported without the -50 or -51 modifier appended.” deleted Policy Guidelines

11/2003: Reviewed by MPAC, “A facet block with intra-articular injection using local anesthetic, corticosteroid or phenol is considered medically necessary for relief of facet-related low back pain” changed to “Two Facet Blocks for Treatment of Back Pain within a calendar twelve month period is considered medically necessary, more than two facet blocks within a calendar twelve month period is considered a trigger point injection and is reimbursed accordingly.” “A re-injury is eligible for additional facet blocks” deleted Policy section

1/21/2004: The following coding guideline deleted from the “Policy” section; “Only one facet joint block at each level (e.g., C3, C5, L1, L2, T1, T2, or S1) is medically necessary. Multiple blocks at the same level are not medically necessary. No allowance will be made for multiple injections or bilateral injections at the same level of the spine (added 10-4-2002).” Code Reference section reviewed with no changes

3/25/2004: Reviewed by MPAC, “Two facet blocks at each level within a calendar twelve month period with intra-articular injection using local anesthetic, corticosteroid or phenol is considered medically necessary for relief of facet-related low back pain. More than two facet blocks within a calendar twelve month period is considered a trigger point injection and is reimbursed accordingly. Any injection must be accompanied by concurrent physical therapy.” changed to “Four (4) sessions per calendar year [maximum of three (3) facet blocks per session] using local anesthetic, corticosteroid or phenol with concurrent physical therapy is medically necessary for relief of facet-related back pain.”

5/5/2004: Code Reference section updated, CPT code 64472, 64476 moved to covered from non-covered

10/6/2004: Policy section revised to include “Destruction of the paravertebral facet joint nerve by a neurolytic agent (chemical, thermal, electrical, radiofrequency) is not covered, except in the extremely rare circumstance as a last resort.” Code Reference section updated, CPT codes 64622, 64623, 64626, 64627 added, CPT code 64470, 76005 description revised, ICD-9 diagnosis code 721.0, 721.1, 721.2, 721.3, 722.81, 722.82, 722.83, 724.1, 738.4 added

3/31/2005: Pain Management Subcommittee revisions reviewed by MPAC and approved, "Four (4) sessions per calendar year [maximum of three (3) facet blocks per session] using local anesthetic, corticosteroid or phenol with concurrent physical therapy is medically necessary for relief of facet-related back pain." which was added 3/25/2004 was changed to "Two (2) sessions per calendar year [maximum of three (3) facet blocks per session] using local anesthetic, corticosteroid or phenol with concurrent physical therapy is medically necessary for relief of facet-related back pain" Policy section, "Concurrent as defined in this policy is within two weeks before or after the facet block." added Policy section, "All facet blocks must be done utilizing fluoroscopy for injection" added Policy section, "Destruction of the paravertebral facet joint nerve by a neurolytic agent (chemical, thermal, electrical, radiofrequency) is not covered, except in the extremely rare circumstance as a last resort." which was added 10/6/2004 changed to "Destruction of the paravertebral facet joint nerve by thermal (non-pulsed) radiofrequency is not covered, except in the extremely rare circumstances as a last resort." Policy section "Under any and all circumstances, pulsed radiofrequency or chemical destruction is not covered." revised Policy section.  this policy change is effective June 1, 2005.

5/6/2005: Code Reference section reviewed, no changes

5/31/2006: Policy updated. Physical Therapy requirement removed from policy.

12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

2/16/2009: "not covered" changed to "not medically necessary"  

03/11/2010: Coding Section revised for 2010 CPT4 and HCPCS revisions

12/30/2010:  Medically necessary policy statement revised to add "per level" for clarity purposes:  Two sessions per level per calendar year [maximum of three (3) facet blocks per session] using local anesthetic, corticosteroid or phenol are considered medically necessary.

 

SOURCE(S)

Hayes Medical Technical Directory

Blue Cross Blue Shield of Tennessee (added 11/2003)

Regence Blue Cross and Blue Shield of Utah, LMRP Database ID Number L9789 (added 11/2003)

Empire Medicare Services, LMRP Database ID Number L3592 (added 11/2003)

Noridian Administrative Services, LLC, LMRP Database ID Number L10810 (added 11/2003)

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

Code Number

Description

CPT-4

 

0213T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance or thoracic; single level (New 1-1-2010)

0214T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance or thoracic; second level (List separately in addition to code for primary procedure) (New 1-1-2010)

0215T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance or thoracic; third and any additional level(s)  (List separately in addition to code for primary procedure) (New 1-1-2010)

0216T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single layer (New 1-1-2010)

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) (New 1-1-2010)

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) (New 1-1-2010)

64470

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level (Deleted 12-31-2009)

64472

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) (Deleted 12-31-2009)

64475

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level (Deleted 12-31-2009)

64476

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (Deleted 12-31-2009)

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 (New 1-1-2010)

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) (New 1-1-2010)

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) (New 1-1-2010)

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 (New 1-1-2010)

64494

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral: second level (List separately in addition to code for primary procedure) (New 1-1-2010)

64495

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral: third and any additional level(s)  (List separately in addition to code for primary procedure) (New 1-1-2010)

64622

Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level

Note: This is covered in extremely rare circumstances as a last resort.

64623

Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Note: This is covered in extremely rare circumstances as a last resort.

64626

Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

Note: This is covered in extremely rare circumstances as a last resort.

64627

Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Note: This is covered in extremely rare circumstances as a last resort.

77003

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction 

ICD-9 Procedure

04.81

Injection of anesthetic into peripheral nerve for analgesia

ICD-9 Diagnosis - This is not intended to be a comprehensive list of codes.

721.0, 721.1, 721.2, 721.3

Spondylosis and allied disorders code range

722.81, 722.82, 722.83

Postlaminectomy syndrome code range

724.1

Pain in thoracic spine

724.2

Lumbago

738.4

Acquired spondylolisthesis 

HCPCS

 

 

 

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