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| Medical Policy: | Z-61-015 |
| Topic: | Paravertebral Facet Joint Nerve Blocks |
| Section: | Miscellaneous |
| Effective Date: | October 1, 2016 |
| Issue Date: | October 3, 2016 |
| Last Reviewed: | April 2015 |
Facet joints (zygapophysial joints) are paired synovial joints located in the posterior compartment of the spinal column. They consist of the posterolateral articulation between vertebral levels, connecting the vertebral bodies to each other. Facet joint injections (intraarticular injections and medial branch blocks) in the cervical, thoracic and lumbar regions of the spine are used to treat chronic back pain from facet joint origin. The Facet joint injections are usually 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 with or without a corticosteroid agent. is injected to temporarily denervate the facet joint. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Paravertebral facet joint nerve blocks may be considered medically necessary when ALL of the following criteria are met:
- Back pain (cervical, thoracic, lumbar)* for at least 3 months and has not responded to conservative therapy (i.e., physical/chiropractic therapy, activity modification, non-steroidal anti-inflammatory drugs, muscle relaxants, and non-narcotic analgesics); and
*Conditions:
Backache
Cervicalgia
Cervicocranial syndrome
Cervical, thoracic, lumbar sprain and strain
Disc degeneration
Dorsalgia
Dorsopathies
Fracture- late effects
Low back pain
Lumbago with sciatica
Muscle spasm of back
Occipital neuralgia
Pain in thoracic spine
Postlaminectomy syndrome
Sciatica
Spinal enthesopathy
Spondylosis
Spondylolisthesis
Spondylopathy - Pain is interfering with functional activities; and
- Pain is non-radicular (radiculopathy-[a disorder of spinal nerve roots ruled out by MRI in patients with complaints of pain radiating to upper/lower extremities); and
- No prior history of vertebral fusion at the levels being treated; and
- Pain exacerbated by extension and prolonged standing/sitting and is relieved by rest; and
- Other treatable causes of pain (i.e., tumors, infection) have been ruled out; and
- The paravertebral facet joint nerve blocks meets the criteria for EITHER of the injections below:
- A diagnostic paravertebral facet joint nerve block is performed to determine chronic pain is of facet joint origin; or
- A therapeutic paravertebral facet joint nerve block is performed to treat pain when a diagnostic paravertebral facet joint nerve block provided at least 50% pain relief.
All other indications are denied as not medically necessary.
Ultrasound guidance for facet joint injections is considered experimental/investigational and therefore non-covered because there is insufficient clinical evidence of its safety and effectiveness.
| Place of Service: Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Paravertebral Facet Joint Nerve Blocks is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
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. |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
05/2015, Criteria Revised for Paravertebral Facet Joint Nerve Blocks
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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