Facet Joint Interventions Checklist

Documentation supports that one of the following facet joint intervention procedures (i.e., Intraarticular (IA) Facet Joint Injections, Medial Branch Block (MBB), and/or Radiofrequency Ablations (RFA)) is for the diagnosis and treatment of chronic pain.

Documentation supports that a limitation to receiving a facet joint intervention is NOT present:

• Being performed without CT or fluoroscopy guidance
• Intervention on more than one spinal region per session
• Multiple blocks (e.g., epidural injections, sympathetic blocks, trigger point injections etc.) being provided to the patient on the same day without medical necessity clearly documented.
• Three or four-level procedures bilaterally without sufficient documentation of medical necessity.
• Extended time (two years or more) between radiofrequency ablations without repeat of diagnostic procedures.
• Therapeutic intraarticular facet injections being performed without documentation of why radiofrequency ablation (RFA) cannot be performed.
• Other limitation

Documentation supports that one of the following contraindications is NOT present:

• Intraarticular and extraarticular facet joint prolotherapy
• Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation
• Intra-facet implants
• Facet joint procedure performed after anterior lumbar interbody fusion (ALIF)
• Definitive clinical and/or imaging finding pointing to a specific diagnosis other than facet joint syndrome
• Diagnostic injections or MBB at the same level as the previously successful RFA procedure
• Other contraindication

Pain Documentation

Documentation includes a pain or disability scale to support moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficits.

Pain assessment is performed at baseline AND after each procedure using the SAME pain or disability scale.

Documentation supports that pain was present for a minimum of 3 months with failure of noninvasive conservative management (as tolerated).

General Documentation Requirements for Facet Joint Interventions

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)

Documentation supports that there is not a non-facet pathology per clinical assessment or radiology studies that could explain the patient’s pain (including but not limited to factures, tumors, infection, or significant deformity

Diagnostic Facet Joint Procedures (IA or MBB)

Indication if request is for an initial or second diagnostic procedure

Subsequent Diagnostic Facet Joint Procedure

Documentation of a minimum of at least two weeks between the initial diagnostic procedure and the second diagnostic procedure.

For the second diagnostic procedure, documentation of a positive response of at least 80% relief of primary pain after the first diagnostic procedure.

Documentation to support 4 or less diagnostic joint sessions within a 12-month period.

Therapeutic Facet Joint Procedures (IA)

Indication if 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.

Documentation of 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.

Documentation of why the beneficiary is not a candidate for radiofrequency ablation.

Documentation to support 4 or less therapeutic joint sessions within a 12-month period.

Facet Joint Denervation (RFA)

Indication 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.

For 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.

Documentation to support two (2) or less thermal radiofrequency ablations, for each covered spinal region, within a 12-month period