Prior Authorization Details

Facet Joint Interventions

National Government Services will begin accepting PARs for Facet Joint Intervention codes on 6/15/2023 for services provided beginning on or after 7/1/2023.  

To meet coverage criteria, the patient’s medical record must contain documentation that fully supports the medical necessity for the services requested.  

Checklist of PAR information to include:  

General Documentation Requirements

  • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit;
  • Relevant medical history;
  • Results of pertinent tests/procedures;
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria:

  1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain OR disability scale*;
  2. Pain present for minimum of three months with documented failure to respond to noninvasive conservative management (as tolerated);
  3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst);
  4. There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity.

Diagnostic (MBB or IA) Facet Joint Injections (64490, 64491, 64493, 64494)

Requirements for the FIRST diagnostic procedure:

  • Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain OR disability scale;
  • Pain present for minimum of three months with documented failure to respond to noninvasive conservative management (as tolerated);
  • Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst); AND
  • There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient’s pain, including but not limited to fracture, tumor, infection, or significant deformity.

Requirements for the SECOND confirmatory procedure:

  • Meets requirements for the first diagnostic; AND
  • After the first diagnostic procedure, there is at least 80% consistent relief of primary pain.
  • The second diagnostic procedure may only be performed a minimum of two weeks after the initial diagnostic procedure. Exception to the two weeks duration may be considered on an individual basis and must be clearly documented in the medical record.

Note: Frequency limitation: for each covered spinal region no more than four diagnostic joint sessions will be reimbursed per rolling 12 months.

Therapeutic (IA) Facet Joint Injections (64490, 64491, 64493, 64494)

  • Indicate if this request is for an initial or subsequent therapeutic procedure; AND
  • Documentation of two diagnostic facet joint procedures with each providing at least 80% of pain relief; AND
  • Subsequent therapeutic facet joint procedures at the same anatomic site with at least 50% pain relief for at least three months from the prior therapeutic procedure or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale, AND
  • Documentation of why the beneficiary is not a candidate for RFA.

Note: Frequency limitation: For each covered spinal region no more than four therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Radiofrequency Ablation (64633, 64634, 64635, 64636)

  • Indicate if this request is for an initial or subsequent facet joint denervation procedure; AND
  • Documentation must support at least two diagnostic MBBs with each one providing at least 80% of pain relief, AND
  • Subsequent thermal facet joint RFA at the same anatomic site with at least 50% of pain improvement for at least six months or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale.

Note: Frequency limitation: For each covered spinal region no more than two radiofrequency sessions will be reimbursed per rolling 12 months.

Revised 8/9/2024