For the purpose of this policy, chronic pain is defined as continuous or intermittent pain persisting six months or more, and unresponsive to conservative measures. Facet joint block is one of the methods used to document/confirm suspicions of posterior elemental biomechanical pain of the back. The patient with this condition usually has back pain that does not have a strong radicular component, there is no associated neurologic deficit and the pain is aggravated by hyperextension or rotation of the spine.

Facet joint injections are performed under fluoroscopic guidance to assure accurate placement of the needle in the facet joint or on the medial nerve branch of the facet joint. A long acting local anesthetic agent is injected to temporarily denervate the facet joint. After a satisfactory block has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged abolition of the low back pain suggests that facet joints were the source of the symptoms.

NOTE:

Assessment of the outcome of this procedure depends on the patient's responses; it is therefore important to make a careful pre-operative evaluation and educate the patient about this procedure.

Multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. It is a prudent medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If this procedure fails to produce the desired effect or rules out the diagnosis, the provider may proceed to the next logical test or treatment as appropriate.

Indications for suspicion of facet joint pain

The decision to treat chronic pain by invasive or destructive procedures must be based on a systematic assessment of the location, intensity, and pathophysiology of the pain. A detailed pain history is essential. This includes prior treatments and responses. Complete assessment of pain may require an assessment of psychological factors such as any underlying psychopathology, effects of the pain on behavior and emotional stability, coping strategies, and the likelihood of compliance with potential regimens. Patient diaries and self-report scales are useful in monitoring response to injections.

Nerve blocks are used for both diagnostic and therapeutic purposes:

• Diagnostic blocks are useful in:
  • Assessing the relative contribution of sympathetic and somatosensory nerves in the pain syndrome; and,
  • Localizing the nerve(s) responsible for the pain or neuromuscular dysfunction particularly when multiple sources of pain are potentially present.
• Therapeutic blocks include the use of anesthetic or neurolytic substances for the long-term control of pain.

Services performed for conditions not identified on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Limitations

• Radiculopathy secondary to nerve root involvement must be ruled out by physical/electrophysiologic examination.
  
  
• Documentation in the patient's medical record must indicate how the provider arrived at the suspected diagnosis. As an example, the patient had back pain aggravated by hyperextension or rotation of the spine without a strong radicular component and no associated neurologic deficit.
  
  
• Providing multiple modalities such as epidural block, bilateral sacroiliac joint injections, lumbar sympathetic blocks on the same day as facet joint blocks or providing more than three levels of facet joint blocks on the same day is not considered medically necessary. We would not expect to see other pain management modalities performed on the same date of service as facet joint blocks.
  
  
• Monitored anesthesia care (MAC) is usually not necessary for paravertebral facet joint blocks except under extenuating circumstances and will therefore be denied as not medically necessary without supporting documentation.

Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

The frequency for therapeutic blocks should be two months or longer between each injection(s), provided that at least > 50% relief is obtained for six weeks. In the therapeutic phase, the interventional procedures should be repeated only as necessary according to the medical necessity criteria, and these are limited to a maximum of six times (not injections) per region for a period of 1 year. 

A series of 2-3 injections may be medically necessary for diagnostic blocks to establish consistency of results, particularly if diagnostic blocks are to be followed by neurolysis. No more than three levels, unilaterally or bilaterally, will be allowed for this procedure unless acceptable justification is presented. 

Documentation Requirements

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available on request.

The medical record must include the patient's history, physical and adequate documentation of the response to the nerve blocks. The pre-operative evaluation leading to suspicion of the presence of the facet joint pathology must be explicitly documented in the patient's medical record along with the post operative conclusions.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

• Codes 64490–64495 must not be used for local anesthesia during surgical procedures. Local anesthesia by the surgeon is included in the surgical procedure.
• Codes 64490 or 64493 must be used to bill for the first vertebral level blocked.
• Only one unit of code 64490-64495 may be submitted for a date of service.
• CPT codes 64491 or 64494 must be used to bill for the second level blocked.
• CPT codes 64492 or 64495 may be billed for the third and any additional level(s).
• Only one unit per code is allowed regardless of the number of pharmacologic agents injected at the same site; e.g., steroids and anesthetics.
• Modifier 50 (bilateral procedure) MUST be included with the appropriate code(s) for any level to denote that BILATERAL blocks were performed at that level. If modifier 50 is not appended to denote bilateral, the service(s) will be considered and paid as unilateral.
• Modifier -LT (left) or -RT (right) may be used with the appropriate code(s) for any level to denote that UNILATERAL blocks were performed at that level.
• Modifier 76 should be appended to denote that a service was repeated by the same physician. This modifier indicates the difference between duplicate services and repeated services.
• Injecting any substance through the needles including small amounts of contrast to confirm the position of the needle is an integral part of the procedure and it is not reimbursed separately.
• When destruction of the facet joint nerve is performed on the same date of service following the block, only the code for nerve destruction will be allowed. The facet nerve block procedure is included in the facet nerve destruction.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.