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FAQs – Prior Authorization: Facet Joint Injections

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Pain and Disability Scales

Does the same scale need to be used before and after a procedure?
- - Yes. This is to ensure the percentage requirement is met per our LCD to proceed with the next procedure. Per the LCD: Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment.
  - Using the same scale before and after provides a measurable account of the patient's pain relief.
  - Avoid documenting pain ranges (i.e., 2-8/10) that may cause confusion and make it difficult to determine the patient's baseline pain assessment. We encourage you to specify the patient's pain level in relationship to the area of the body experiencing pain or with activity.
  Published: 04.26.24
Is a functional/disability assessment needed at baseline?
- - No. However, you may choose to do a functional assessment before and after a procedure or to demonstrate moderate to severe pain. A functional assessment can assist in determining if a patient's functional abilities have improved. For radiofrequency ablations, a procedure can result in 50% improvement in pain for at least 6 months or at least 50% consistent improvement in previously painful movements using the same scale.
  Published: 04.26.24
Can I use a functional/disability scale that combines both pain and function before and after a procedure?
- - Yes. If the same scale is used before and after an MBB procedure and can demonstrate the 80% improvement in pain using the same agent.
  - Yes. If the same scale is used to assess a previous RFA and it demonstrates a 50% improvement in pain and/or functioning for at least 6 months.
  Published: 04.26.24
Which pain and/or disability scale is the best to use?
- - A provider can use whichever assessment scale they like. Our LCD mentions several. Regardless of which pain scale a provider uses, they need to use the same scale before and after each procedure.
  Published: 04.26.24
When should I perform the MBB post procedure pain assessment?
- - It is recommended the post pain assessment is conducted during the anesthetic phase of the MBB procedure, usually within hours to a few days later. It is recommended for providers to conduct a post procedure pain assessment as soon as possible. It is possible for a patient to return to their baseline pain level within hours to days later. Conducting a post procedure assessment weeks or months later may not yield the results needed to proceed with the next procedure.
  Published: 04.26.24
Is a telephone call encounter acceptable when doing a post pain assessment?
- - Yes. Providers need to utilize the same pain assessment scale that was used pre-procedure. It needs to be properly documented in the medical record as a telephone encounter call.
  Published: 04.26.24

Frequency of Sessions

What is considered a session?
- - A session can either be unilateral or bilateral.
  - A left side session done on one day and the right side on another day equals 2 sessions.
  Published: 04.26.24
How many MBB sessions can a patient have within a year?
- - A patient can have 4 MBB sessions per spinal region in a 12-rolling month period. This is not a calendar year. For example:
    - Cervical MBBs performed on 11/2/2023, 12/2/2023, 1/4/2024, and 2/6/2024 equals 4 sessions.
  Published: 04.26.24
How far apart do the MBB sessions have to be?
- - Per our LCD the minimum amount of time is 2 weeks apart. MBB procedures that are very far apart from one another are reviewed on a case-by-case basis.
  Published: 04.26.24
How many RFA sessions can a patient have within a year?
- - A patient can only have 2 RFA sessions per region in a 12-rolling month period. This is not a calendar year. For example:
  - A patient receives unilateral RFA sessions.
    - RT RFA procedure L3-4, L4-5 on November 1, 2023 = session 1
    - LT RFA procedure L3-4, L4-5 on November 20, 2023 = session 2
    - Patient's pain returns September 15, 2024 in the same region
      - Documentation shows sustained 50% improvement for at least 6 months using the same scale
      - Cannot receive another RFA until after November 1, 2024 at the earliest
  - A patient receives bilateral RFA sessions.
    - BL RFA procedure L3-4, L4-5 on November 1, 2023 = session 1
    - Patient's pain returns in the same area on May 15, 2024
      - Documentation shows patient sustained at least 50% improvement for at least 6 months using the same scale
      - BL RFA procedure L3-4, L4-5 performed on May 30, 2024 = session 2
    - Patient cannot receive another RFA until on/after November 30, 2024 at the earliest
      - Patient needs to have 50% improvement for at least 6 months between sessions using the same scale
  Published: 04.26.24
Is it possible to complete a thoraco-lumbar facet level joint intervention within one session?
- Billing contiguous facet interventions in the thoraco-lumbar levels, T12-L1 and L1-2, during one session will be allowed and considered one spine (lumbar) region. A facet joint intervention targeting the thoraco-lumbar region will be considered and counted as one lumbar spine session.
  
  Diagnostic and Therapeutic Procedures
  
  For facet joint injections of the T12-L1 and L1-2 levels, or nerves innervating that joint, use 64490 and 64494 once.
  
  Neurolytic Destruction of the Nerves (RFA)
  
  For neurolytic destruction of the nerves innervating the T12-L1 and L1-2 paravertebral facet joints, use 64633 and 64636 once.
  
  Published: 01.30.24

Procedure Requirements

What are the criteria for an intraarticular (IA) injection?
- - For a patient to receive an IA injection there must be specific documentation explaining the need for an IA over the MBB to RFA route. Documentation which may indicate one or more of the following:
    - Significant deformity or other anatomic restrictions
    - Implanted device
    - A medical condition which indicates these are the best option for the patient
  - These requests are reviewed on a case-by-case basis. Any request which indicates it is a patient's preference will most likely receive a non-affirmed decision.
  Published: 04.26.24
If an MBB procedure did not yield the necessary results needed, could we then pursue the next procedure?
- - No. Each MBB diagnostic injection requires at least 80% pain improvement before moving on to the next procedure.
  Published: 04.26.24
Can a third MBB be performed at a different level if the first 2 MBBs were inconclusive?
- - Yes. If the reason for performing a third MBB is present in the documentation. We recognize that a patient's pain generator in the same region may be at a different level than what was originally intended. Keep in mind a patient can only have 4 MBBs sessions per region in a 12-rolling month period. The patient will still need to have 2 confirmatory blocks before proceeding to an RFA.
  Published: 04.26.24
If the RFA in a region did not demonstrate 50% improvement for at least 6 months, we can then pursue doing an intraarticular (IA) injection in the same location?
- - No. When a previous MBB or RFA did not work, an IA at the same location/level is against policy as outlined in our LCD.
  Published: 04.26.24
If the RFA did not work, can another MBB be conducted at the same levels?
- - No. When an RFA did not work, performing another MBB at the same levels goes against our LCD policy.
  Published: 04.26.24
If it has been greater than 2 years since the last RFA, it is okay to do another RFA in the same location/level?
- - No. Per our LCD if it has been greater than 2 years, then 2 confirmatory diagnostic MBBs need to be conducted again before doing another RFA.
  Published: 04.26.24

Miscellaneous

Will a prior authorization request receive a non-affirmed decision if IV sedation is mentioned as part of the plan?
- - No. The mention of sedation or IV conscious sedation will not result in an automatic non-affirmed decision. Providers are encouraged to have specific documentation which outlines their reasons for using sedation in the event the use of sedation gets denied on a claim. The LCD does state the use of sedation with MBB procedures is unnecessary and not reasonable but can be reviewed under certain circumstances on appeal.
  Published: 04.26.24
Who is required to submit a prior authorization request?
- - Currently, only those procedures conducted in a hospital outpatient department (HOPD) setting where a type of bill 13x is used.
  Published: 04.26.24
How should the facet levels be documented in the medical record?
- - They should be clearly written to avoid confusion. For example L1-2 or L1/2. Per LCD:
    - The terminology or nomenclature of the facet joint is classified by the specific vertebrae level that forms it (e.g., C4-5 or L2-3). There are two (2) facet joints, right and left, at each spinal level.
  Published: 04.26.24
Does a prior authorization have to be submitted for each procedure?
- - Yes. A prior authorization is only good for 1 claim or date of service. An affirmed UTN cannot be used for multiple dates or procedures.
  Published: 04.26.24
Do epidural steroid injections require prior authorization?
- - No. The HCPC codes for these procedures are not currently required for prior authorization. For more information on epidural steroid injections, you can access our local coverage article (LCA A58731) related to these procedures at: Article – Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
  - For coverage guidance related to epidural steroid injections, you can access our local coverage determination (LCD L39015) from: LCD – Epidural Steroid Injections for Pain Management (L39015).
  Published: 04.26.24
Can a patient receive multiple injections/procedures the same day?
- - No. A patient can only receive one procedure per day. Multiple procedures conducted on the same day could result in a false positive, improper or lack of diagnosis. Per our LCD:
    - 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 transforaminal epidural injection (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.
  Published: 04.26.24

Resources

Local Coverage Article (LCA): Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Local Coverage Determination (LCD): Facet Joint Interventions for Pain Management (L38773)
Prior Authorization Program for Certain Hospital Outpatient Services Operational Guide