Facet Joint Interventions for Pain Management Best Practices

Table of Contents

• Indications and/or Medical Necessity
• Coverage
• Documentation Requirements
• Diagnostic Facet Joint Injections (IA or MBB)
• Therapeutic Facet Joint Injection Procedures (IA)
• Radiofrequency Ablation (RFA)/Denervation
• Limitations
• Not Reasonable and Necessary
• References

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Indications and/or Medical Necessity

The spine is the most common source of chronic pain. Chronic axial spinal pain is one of the major causes of disability. The facet joints can cause axial spinal pain and referred pain in the extremities. The pathology of the pain source is due to facet joints being richly innervated by the nerve fibers from the medial branch of the dorsal ramus of spinal nerves.

Facet joint interventions may be used in pain management for chronic cervical/thoracic and lumbar/sacral pain arising from the paravertebral facet joints. The facet block procedure is an injection of a local anesthetic, with or without a steroid medication, either into the facet joint (IA), or outside the joint space (targeting the medial branch nerve, known as MBB). Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or lumbar/sacral pain confirmed as originating in the facet joint’s medial branch nerve.

See LCD L35936 – Facet Joint Interventions for Pain Management for more information.

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Coverage

Facet joint interventions performed in a HOPD will require PA for dates of service on or after 7/1/2023, for the CPT codes listed in table 1.

Table 1. Facet Joint Intervention CPT codes

*Note: The first CPT code in each color block above is the primary procedure for each intervention type at the specified spinal level. If applicable, any subsequent code must be requested in conjunction with the appropriate primary procedure. For example: the documentation supports three levels of diagnostic interventions of the cervical spine; CPT codes 64490, 64491, and 64492 must be requested in order to fully support the prior authorization request. In addition, multilevel interventions must be supported. Subsequent codes not supported on assessment or with imaging will be nonaffirmed. (Local Coverage Article 57826)

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Documentation Requirements

Providers should include the following documentation with their Facet Joint Interventions PA request:

• Patient assessment by the performing provider as it relates to the patient complaint for that visit;
• Relevant medical history;
• Results of pertinent tests/procedures;
• Signed and dated office visit record/operative report;
• 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;
• 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.

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Diagnostic Facet Joint Injections (IA or MBB)

• CPT codes 64490, 64491, 64492: Cervical/Thoracic
• CPT codes 64493, 64494, 64495: Lumbar/Sacral

Diagnostic procedures should be performed with the intent that if successful, RFA procedure would be the primary treatment goal at the diagnosed level.

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.

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

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Therapeutic Facet Joint Injection Procedures (IA)

• CPT codes 64490, 64491, 64492: Cervical/Thoracic
• CPT codes 64493, 64494, 64495: Lumbar/Sacral

Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet all of the following criteria:

• The patient has had two medically reasonable and necessary diagnostic facet joint procedures with each one providing a minimum of 80% consistent relief of primary (index) pain (with the duration of relief being consistent with the agent used);
• Subsequent therapeutic facet joint procedures at the same anatomic site result in at least 50% consistent pain relief for at least three months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale; and
• Documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device) is clearly documented in the medical record.

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

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Radiofrequency Ablation (RFA)/Denervation

• CPT codes 64633, 64634: Cervical/Thoracic
• CPT codes 64635, 64636: Lumbar/Sacral

RFA uses radio waves to stop medial branch nerves from transmitting pain signals from the injured facet joint to the brain; involves heating a part of the pain-transmitting nerve with a radiofrequency needle to create a heat lesion (resulting lesion prevents the nerve from sending pain signals to the brain).

For an initial RFA to be considered medically reasonable and necessary, the patient must have had two previous successful diagnostic procedures resulting in 80% consistent pain relief of primary pain, with the duration of relief consistent with the agent used.

For subsequent RFA procedures:

• Must be at the same anatomic site;
• Evidence of two diagnostic procedures; and
• Previous RFA provided a consistent minimum of 50% improvement in pain for at least six months or,
• At least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same pain scale.

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

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Limitations

1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and necessary. This includes facet joint interventions done without any guidance, performed under ultrasound guidance, or with MRI.
2. General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor MAC is routinely necessary for IA facet joint injections or MBB and are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.
3. It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar spinal regions. Therefore, facet joint interventions (both diagnostic and therapeutic) are limited to one spinal region per session.
4. It is not routinely necessary for multiple blocks (e.g., epidural injections, sympathetic blocks, trigger point injections, etc.) to be provided to a patient on the same day as facet joint procedures. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or a different level[s]) must be clearly documented in the medical record. For example, the performance of both paravertebral facet joint procedures(s) and a TFESI at the same or close spinal level at the same encounter would not be expected unless a synovial cyst is compressing the nerve root. In this situation, TFESI may provide relief for the radicular pain, while the facet cyst rupture allows nerve root decompression. Frequent reporting of multiple blocks on the same day may trigger a focused medical review.
5. Facet joint IA injections and MBB may involve the use of anesthetic, corticosteroids, anti-inflammatories and/or contrast agents, and does not include injections of biologicals or other substances not FDA designated for this use.
6. One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., MBB, IA injections, facet cyst ruptures, and RFA ablations that are performed during the same day.
7. If there is an extended time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated.
8. Therapeutic IA facet injections are not covered unless there is justification in the medical documentation on why RFA cannot be performed. Facet joint procedures in patients for the indication of generalized pain conditions (such as fibromyalgia) or chronic centralized pain syndromes are considered not reasonable and necessary. Individual consideration may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.
9. In patients with implanted electrical devices, providers must follow manufacturer instructions and extra planning as indicated to ensure safety of procedure.

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Not Reasonable and Necessary

1. IA and extraarticular facet joint prolotherapy
2. Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation.
3. Intra-facet implants
4. Facet joint procedure performed after anterior lumbar interbody fusion or ALIF.
5. Definitive clinical and/or imaging findings pointing to a specific diagnosis other than facet joint syndrome
6. Diagnostic injections or MMB at the same level as the previously successful RFA procedure

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References

• Facet Joint Interventions for Pain Management LCD (L35936)
• Billing and Coding: Facet Joint Interventions for Pain Management (A57826)
• CMS PA Program for Certain Hospital OPD Services – Operational Guide

Posted 6/14/2023