Facet Joint Interventions for Pain Management

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. 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 L38765 — Facet Joint Interventions for Pain Management for more information.)

Coverage
Facet joint interventions performed in a hospital outpatient department (HOPD) will require prior authorization (PA) for dates of service on or after July 1, 2023, for the Current Procedural Terminology (CPT®) codes listed in table 1.

Table 1. Facet Joint Intervention CPT® Codes

Documentation Requirements

Providers should include the following documentation with their facet ioint interventions PA request:

• Clear indication of what is being requested
• History and physical 
• Physician orders and progress notes 
• Diagnostic test results 
• Procedure records 
• Pain history to include location, severity and duration 
• Evidence of failed conservative management 
• Disability scale rating or an H/P that clearly describes functional disability for each new episode of pain
• Patient response to prior facet joint interventions, if applicable
• Medical history records
• Signature attestation form, if applicable

Diagnostic Facet Joint Injections
Diagnostic facet joint procedures are used to diagnose facet syndrome with the injection of a local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). Intraarticular (IA) facet blocks as a diagnostic test may only be reasonable and necessary if medial branch blocks (MBB) cannot be performed. Restrictions must be clearly documented in the medical record (anatomic restrictions or an indication to proceed with therapeutic IA injections). Diagnostic procedures should be performed with the intent that if successful, radiofrequency ablation 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; and
• Pain present for minimum of three (3) months with documented failure to respond to noninvasive conservative management (as tolerated); and
• 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 percent 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-week 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 (4) diagnostic joint sessions will be reimbursed per rolling 12 months.

Therapeutic Facet Joint Injection Procedures (IA) 
Therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet all the following criteria:

• The patient has had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a minimum of 80 percent consistent relief of primary (index) pain (with the duration of relief being consistent with the agent used); and
• Subsequent therapeutic facet joint procedures at the same anatomic site result in at least 50 percent consistent pain relief for at least three (3) months from the prior therapeutic procedure or at least 50 percent 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 (4) therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Radiofrequency Ablation (RFA) and Denervation
RFA uses radio waves to stop medial branch nerves from transmitting pain signals from the injured facet joint to the brain; involved 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).

A facet joint denervation is the preferred method of treatment for facet joint syndrome. If a denervation is not an option, there needs to be supporting documentation providing reasons why this intervention cannot be performed.

The thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who meet all the following criteria:

1. Initial Thermal RFA
   After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80 percent sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used) 
    
2. Repeat Thermal Facet Joint RFA
   1. After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80 percen sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used); and
   2. RFA is at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50 percent improvement in pain for at least six (6) months, or at least 50 percent consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale

 
The HCPCS Codes — The HCPC codes for radiofrequency ablation and denervation prior authorization include:

Cervical or Thoracic Joints

• 64633 (single level)
• 64634 (additional levels — must be reported with 64633)

Lumbar or Sacral Joints

• 64635 (single level)
• 64636 (additional levels — must be reported with 64635)
   

Frequency limitation — For each spinal area there can be no more than two (2) RFA sessions over a 12-month rolling period.

Billing/Coding Alerts — For more information related to billing and coding please refer to the LCA Billing and Coding: Facet Joint Interventions for Pain Management (A58350).

Limitations/Contraindications — For more information related to limitations and contraindications please refer to the LCD Facet Joint Interventions for Pain Management (L38765).

References

• Facet Joint Interventions for Pain Management LCD (L38765)
• Billing and Coding: Facet Joint Interventions for Pain Management (A58305)
• CMS PA Program for Certain Hospital OPD Services — Operational Guide (PDF)
• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services