Facet Joint Injections
© Blue Cross and Blue Shield of Montana
Current Effective Date:
August 27, 2013
Original Effective Date:
December 18, 2009
May 27, 2013
March 8, 2011, April 4, 2012, December 4, 2012; April 25, 2013
Back pain is the second most common neurological ailment in the United States—only headache is more common. Fortunately, most occurrences of low back pain go away within a few days; others may take much longer to resolve or may lead to more serious conditions. Acute or short-term low back pain generally lasts from a few days to a few weeks. Chronic back pain is pain that persists for more than three months; it is often progressive and the cause can be difficult to determine. Back pain that arises from a spinal source may originate from the vertebrae, intervertebral discs, spinal cord, nerve roots, facet joints, ligaments, muscles, or sacroiliac, atlanto-axial and atlanto-occipital joints. Common causes of back pain are muscle strains and spasms, sciatica and herniated intervertebral discs.
Facet joints, also called zygapophysial or “Z” joints, are located on the posterior spine on each side of each vertebra, where they overlap the neighboring vertebrae. The facet joints provide stability and give the spine the ability to bend and twist. A facet joint injection is an injection of a long acting local anesthetic agent and/or steroid into the paravertebral facet joint, medial branch nerve or facet joint nerve under fluoroscopic guidance. When optimally performed, the injection is made directly into the joint space, though for generations anesthesiologists have been successful in injecting around the joint. Pain relief following a precise intra-articular injection confirms the facet joint as the source of pain.
The 2007 ASIPP (American Society if Interventional Pain Physicians) Guidelines describes two phases of facet joint injection therapy: the diagnostic and the therapeutic phases. Diagnostic facet joint injections with a local anesthetic are used in the cervical, thoracic or lumbar spine to verify the specific area generating pain prior to a facet joint denervation procedure or other medical management. Therapeutic facet joint injections are based on the outcome of a diagnostic facet joint injection with the patient obtaining sufficient relief for a meaningful period of time. When pain recurs, a repeat injection with long acting local anesthetic and steroid will generally provide pain relief for four to eight weeks.
In addition to fluoroscopic or computed tomography (CT) guidance, ultrasound-guided imaging may also be used in facet or transforaminal injections. Proposed advantages of US guidance are:
- real time monitoring without ionizing radiation,
- more cost effective, and
Prior authorization is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.
- The back or neck pain is chronic (i.e., persisting for more than 3 months); AND
- Conservative therapy (e.g., physical and/or chiropractic therapy, oral analgesia and/or steroids and/or relaxants, activity modification) fails or is not feasible; AND
- No evidence of contraindications, such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain; AND
- The pain is non-radicular (i.e., for patients with a complaint of radiation of pain into an upper or lower extremity), radiculopathy has been ruled out by an magnetic resonance imaging (MRI), and no signs of dural tension exists (as evidenced by negative "straight leg raise" on physical exam); AND
- Suspected spinal facet joint syndrome, as evidenced by low back pain that is exacerbated by extension and by prolonged standing/sitting and that is relieved by rest; AND
- Absence of a prior fusion at the clinically suspect levels; AND
- Absence of an unexplained neurological deficit; AND
- Repeat interventions only upon return of pain and deterioration in functional status.
*Schedule: When the above criteria are met, the following schedule for diagnostic and therapeutic facet joint injection(s) that are performed under fluoroscopic guidance may be considered medically necessary:
1. DIAGNOSTIC PHASE (to determine origin of patient’s pain)
- A diagnostic block of the joint, or nerves innervating the joints, using a local anesthetic with or without corticosteroids is given initially.
- In the diagnostic phase, a patient may receive one (1) injection per level per side in a seven (7) day period to determine the origin of the patient’s pain.
- If the diagnostic block provides pain relief, therapeutic facet injections are given no sooner than one week after a successful diagnostic block at that spinal region, (i.e., cervical, thoracic or lumbar).
2. THERAPEUTIC PHASE (after the diagnostic phase is completed)
- In the therapeutic phase facet joint injection frequency is limited to every two (2) months, provided that each injection yields >50% relief for at least six (6) weeks.
- Therapeutic facet joint injections should be repeated only as necessary according to the medical necessity criteria, and are limited to no more than six (6) times per year per spinal region for local anesthetic and steroid blocks.
- If therapeutic facet injections are to be performed at a different spinal region:
- A positive diagnostic block is required at that region; AND
- The therapeutic frequency is limited to every two (2) months per spinal region; AND
- Therapeutic improvement is required for additional facet injections; AND
- All regions should be treated at the same time whenever possible, provided all procedures can be performed safely.
Not Medically Necessary
Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.
03.96, 721.0, 721.1, 721.2, 721.3, 721.41, 721.42, 722.81, 722.82, 722.83, 723.1, 724.1, 724.2, 724.3
G89.29, G89.4, M54.2, M54.6, M54.89, M54.9
64490, 64491, 64492, 64493, 64494, 64495, 77003, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T
- National Institutes of Health—National Institute of Neurological Disorders and Stroke: Low Back pain Fact Sheet. Pub No. 03-5161 (2003 July).
- Bogduk, N. Practice guidelines for spinal diagnostic and treatment procedures. International Spine Intervention Society (2004):86-94.
- Zakaria, D. and B. Skidmore. Facet joint injection as a diagnostic and therapeutic tool for spinal pain: a review of clinical and cost effectiveness. Canadian Agency for Drugs and Technologies in Health (2007 May) Technology Report:1-20.
- eMedicine—Wagner, A.L., et al. Paraspinal injections—facet joint and nerve root blocks. eMedicine Specialties (2009 May 6). Available at <http://www.emedicine.medscape.com> (accessed – 2009 June 2)
- Chuan-Bing Wen, Yue-e Dai, et al. A Clinical Trial of Ultrasound-Guided Facet Joint Injections in the Lumbar Spine. American Society of Anesthesiologists, Annual Meeting Abstracts (A981) (2009 October 19) Available at www.asaabstracts.com (accessed – 2010 March 30).
- Manchikanti, L., Singh, V., et al. Interventional techniques in the management of chronic pain: part 1.0 (from the Association of Pain Management Anesthesiologists). Pain Physician (2000) 3(1):7-42.
- Boswell, M.V., Trescot, A.M., et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician (2007) 10:7-111.
- Joseph M. Neal, M.D., Christopher M. Bernards, M.D., et al. ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2008; 33:404-15.
- Sehgal, N., et al. Systematic Review of Diagnostic Utility Of Facet (Zygapophysial) Joint Injections In Chronic Spinal Pain: An Update. Pain Physician 2007; 10:213-28.
- Narouze, S., Vydyanathan, A., et al. Ultrasound-Guided Cervical Selective Nerve Root Block: A Fluoroscopy-Controlled Feasibility Study. Regional Anesthesia and Pain Medicine 2009 July/August; 34(4):343-8.
- Ultrasound Guided Diagnostic Cervical Medial Branch Block. Trial Identifier #00896688. McMaster University 2009. (Available at www.clinicaltrials.gov (accessed June 11, 2012).
||Changed the denial from "not medically necessary" to investigational". Changed requirement from 3 medical branch blocks to 2 medial branch blocks. Updated description, rationale and references. |
||Policy updated with literature review through August 2011; references added and reordered; statement on radiofrequency denervation clarified; laser denervation, cryodenervation, and therapeutic blocks added as investigational. Radiofrequency removed from title. |
||Policy updated with literature review through August 2012; reference numbers 10 and 33 added. Chemodenervation added to investigational policy statement.|
||Policy formatting and language revised. Title changed from "Facet Joint Denervation" to "Facet Joint Injections". Added schedule criteria to the Medically Necessary statement. Investigational statement changed to Not Medically Necessary. Removed codes 64622, 64623, 64626, 64627, 64633, 64634, 64635, 64636, 64999. Added codes 64490, 64491, 64492, 64493, 64494, 64495, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T.|