Facet Blocks for Treatment of Back Pain

POLICY NUMBER

L.7.01.407

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 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

Federal Employee Program (FEP) Members: Follow FEP Medical Policy Guidelines.

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.

Federal Employee Program (FEP) Members:

A successful trial of controlled diagnostic medial branch blocks consists of 2 separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in at least a 50% reduction in pain for the duration of the local anesthetic used (eg, 3 hours longer with bupivacaine than lidocaine). No therapeutic intra-articular injections (ie, steroids, saline, or other substances) should be administered for a period of at least 4 weeks prior to the diagnostic medial branch block. The diagnostic blocks should involve the levels being considered for radiofrequency treatment and should not be conducted under intravenous sedation unless specifically indicated (eg, the patient is unable to cooperate with the procedure). These diagnostic blocks should be targeted to the likely pain generator. Single-level blocks lead to more precise diagnostic information, but multiple single-level blocks require several visits and additional exposure to radiation.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

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 (added10-4-2002).” 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.

02/07/2014: Policy Exceptions section updated regarding coverage criteria for Federal Employee Program (FEP) members. Removed deleted CPT codes 64470, 64472, 64475, 64476, 64622, 64623, 64626, and 64627 from the Code Reference section. Added CPT codes 64633 - 64636 to the Code Reference section.

08/28/2015: Code Reference section updated for ICD-10. Removed deleted CPT code 64622. Removed CPT code 77003.

03/23/2016: Code Reference section updated to add ICD-10 diagnosis codes M47.891 - M47.893. Policy guidelines updated to add medically necessary and investigative definitions.

06/01/2016: Policy number L.7.01.407 added.

10/01/2021: Code Reference section updated to add new ICD-10 diagnosis codes M54.50 - M54.59 effective 10/01/2021.

02/06/2023: Policy reviewed. Policy statements unchanged. Policy Exceptions and Policy Guidelines updated regarding FEP members. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to remove deleted ICD-10 diagnosis code M54.5.

03/14/2024: Policy reviewed; no changes.

08/30/2024: Policy updated to remove the "extremely rare circumstances" language from the Policy and Code Reference sections. Policy Exceptions updated regarding Federal Employee Program (FEP) members.

12/04/2024: Policy reviewed; no changes.

SOURCE(S)

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

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

3. Hayes Medical Technical Directory

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

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

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

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

Covered Codes

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