Facet Joint Interventions for Pain Management - JE Part B

General Documentation Requirements for Facet Joint Interventions- Intraarticular (IA) Facet Joint Interventions, Medial Branch Blocks (MBB), and Radiofrequency Ablations

• Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale
• Presence of pain for minimum of 3 months with documented failure to respond to conservative management
• Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
• Non-facet pathology must be ruled out based on clinical evaluation or radiology studies
• The scales used to assess the measurement of pain and/or disability must be obtained at baseline and documented in the medical record for each assessment (refer to your MAC's LCD/LCA).

Diagnostic Facet Joint Procedures (IA or MBB)

• Indicate if this request is for an initial or second diagnostic procedure
• For the first diagnostic facet joint procedure, documentation must support the criteria outlined in general documentation requirements for facet joint interventions
• Diagnostic procedures should be performed with the intent that if successful, RFA would be considered the primary treatment goal at the diagnosed level(s)
• For the second diagnostic facet joint procedure(s), documentation must support the following:
  • Documentation must support the requirements for the first diagnostic procedure at the same level, and
  • After the first diagnostic procedure, there must be at least 80% of pain relief, and
  • The second diagnostic procedure may only be performed a minimum of 2 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 IA/MBB for each covered spinal region, no more than four (4) diagnostic joint sessions will be considered medically reasonable and necessary per rolling 12 months, in recognition that the pain generator cannot always be identified with the initial and confirmatory diagnostic procedure.

Therapeutic Facet Joint Procedures (IA)

• Indicate if this request is for an initial or subsequent therapeutic procedure
• Documentation of two (2) diagnostic facet joint procedures with each providing at least 80% of pain relief
• Subsequent therapeutic facet joint procedures at the same anatomic site with at least 50% pain relief for at least 3 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 radiofrequency ablation (RFA)
  • Frequency limitation for each covered spinal region no more than four (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Facet Joint Denervation (RFA)

• Indicate if this request is for an initial or subsequent facet joint denervation procedure
• For the initial thermal RFA, documentation must support at least two (2) 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 (6) months or at least 50% improvement in the ability to perform previously painful movements and ADLs, compared to baseline measurement using the same scale
  • Frequency limitation for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.

Note: 64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494. Codes 64492 and 64495 will only be covered upon appeal if sufficient documentation of medical necessity is present.

Resources

• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services (CMS)
• Federal Register