Diagnostic and therapeutic paravertebral facet joint nerve blocks (64490, 64491, 64492, 64493, 64494, 64495, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T) are eligible when performed for the assessment and treatment of chronic pain for patients with any of the following conditions:

• cervical spondylosis without myelopathy
• cervical spondylosis with myelopathy
• thoracic spondylosis without myelopathy
• lumbosacral spondylosis without myelopathy
• spondylosis with myelopathy, thoracic region
• spondylosis with myelopathy, lumbar region
• cervicalgia
• lumbago
• sprains and strains of the cervical, thoracic, and lumbar areas of the neck and back
• sciatica
• sacroiliitis

The decision to treat chronic pain by invasive procedures must be based on a systematic assessment of the location, intensity, and pathophysiology of the pain.  A detailed pain history is essential to determine appropriateness.  This includes prior treatments and responses. 

Paravertebral facet joint nerve blocks are used for both diagnostic and therapeutic purposes. 

Diagnostic blocks are useful in:

1. Assessing the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome; and
2. 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 corticosteroid substances for the long-term control of pain.

A series of injections may be medically necessary to establish consistency of results, particularly if diagnostic blocks are to be followed by neurolysis.  If successful, it is reasonable to repeat this series in the event of a relapse.  However, multiple nerve blocks over a period of several weeks or months is not an effective method of chronic pain management.  It is, therefore, not generally considered reasonable and necessary to perform facet joint nerve blocks more than (4) injections per level, per year.

Paravertebral facet joint nerve block procedures that do not meet the indications and limitations of coverage criteria and do not involve an eligible diagnosis are not considered medically necessary and are not eligible for payment. A participating, preferred, or network 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 should be maintained in the provider's records.

Description

Chronic pain is defined as continuous or intermittent pain that has been unresponsive to conservative measures, persisting three months or more.  Facet joint block is one of the methods used to document/confirm suspicions of posterior elemental biomechanical pain of the spine.

Facet joint injections are generally 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 or corticosteroid 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 the pain, and to record the perceived pain relief effect 4 to 8 hours after the injection.  Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms.

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.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.