BlueCross and BlueShield of Montana Medical Policy/Codes
Facet Joint Injections
Chapter: Surgery: Procedures
Current Effective Date: August 27, 2013
Original Effective Date: December 18, 2009
Publish Date: May 27, 2013
Revised Dates: March 8, 2011, April 4, 2012, December 4, 2012; April 25, 2013
Description

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,
  • noninvasive,
  • more cost effective, and
  • convenience.
Policy

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.

Medically Necessary

BCBSMT may consider facet joint injections that are performed under fluoroscopic guidance medically necessary according to the *schedule outlined below when the following criteria are met:

  1. The back or neck pain is chronic (i.e., persisting for more than 3 months); AND
  2. 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
  3. No evidence of contraindications, such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain; AND
  4. 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 
  5. 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 
  6. Absence of a prior fusion at the clinically suspect levels; AND 
  7. Absence of an unexplained neurological deficit; AND
  8. 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

BCBSMT considers facet injections not medically necessary for the following:

  1. When the above criteria are not met; OR
  2. When there is a history of coagulopathy, systemic and/or local infection, or unstable medical conditions; OR
  3. Additional therapeutic facet injections in the absence of an improvement in pain or function; OR
  4. Therapeutic facet injections more frequently than every two (2) months per spinal region; OR
  5. Therapeutic facet injections more frequently than six (6) times per year per spinal region; OR
  6. In the presence of an unexplained neurological deficit.

Advanced Member Notification

When the criteria for coverage is not met, BCBSMT encourages all participating providers to have a member complete and sign an Advanced Member Notification (AMN) form, stating that BCBSMT will not cover this service, supply, device, or drug. If an AMN is signed prior to delivery of the service, participating providers can balance bill the member. If an AMN is not signed, participating providers are financially liable for the service and cannot balance bill the BCBSMT member for denied services. Services deemed Not Medically Necessary, or Investigational that are provided by an out-of-state (Montana) or Out-of-Network provider are the financial responsibility of the member regardless of a completed AMN.

Refer to the Advanced Member Notification medical policy for more information.  The AMN form is available at www.bcbsmt.com (Click on Providers and then Forms).

Investigational

BCBSMT considers ultrasound (US) guidance of either facet or transforaminal injections experimental, investigational and unproven.

Federal Mandate

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.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. BCBSMT recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

Pain management presents a major challenge to healthcare providers due to complex natural history and unclear etiology of spinal pain. Clinical decision making for diagnosing and treating chronic pain is difficult due to the subjective nature of pain. Although there are clinical studies for facet joint steroid injections, the results vary in respect to the degree and duration of pain relief, and it is difficult to standardize treatment models.

In their 2000 Practice Guidelines, the Association of Pain Management Anesthesiologists (APMA) (6) reported the following regarding facet joint blocks:

“The specific rationale for facet-joint blocks is based on the observation that, if a particular joint is determined to be the source of pain generation, long-term relief can be sought by directing therapeutic interventions at that joint. In managing low back pain, local anesthetic injection into the facet joints or interruption of the nerve supply to the facet joints has been accepted as the standard for diagnosis of facet-joint mediated pain. Since a single joint is innervated by at least two medial branches, two adjacent levels should always be blocked. Effectiveness of facet-joint injections, facet-joint nerve blocks, and facet-joint neurolysis has been reasonably studied, though the results have varied widely. The evidence for lumbar intra-articular injections of steroids with or without local anesthetic is in favor of the injections in well-controlled studies, even though the evidence is not unequivocal. Studies of intra-articular injections showed short-term relief in 46% to 75% of the patients, while long-term relief was seen only in 20% to 36% of the patients following a single injection. The role of medial branch blocks in the diagnosis of facet-joint pain has been well described and is considered superior to intra-articular comparative local anesthetic blocks. However, for therapeutic purposes, the literature is sparse and the few studies which do exist have reported that facet-joint injections and medial branch blocks are of equal value. Multiple reports showing the effectiveness of radiofrequency neurolysis were encouraging. In contrast, most of the positive results of cervical intra-articular injection of corticosteroids and medial branch blocks were from uncontrolled reports.”

In 2007, the American Society of Interventional Pain Physicians (ASIPP) published evidence-based practice guidelines (7) in which the following conclusions were made concerning facet joint injections:

  • Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain.
  • The evidence for therapeutic lumbar intra-articular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections.

Traditionally, facet and transforaminal injections are performed using fluoroscopy or computed tomography (CT). The 2008 ASRA (American Society of Regional Anesthesia and Pain Medicine) (8) Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine discusses transforaminal injection of steroids, stating that these injections have been linked to cases of spinal cord infarction, cortical blindness, paralysis, and death, and that the presumed mechanism of these complications involves unintentional needle entry into a small artery that traverses the intervertebral foramen. Their recommendations for transforaminal injections include that the injection should be confirmed using anterior-posterior and lateral radiography, and when available, monitoring the injection using digital subtraction imaging technology is recommended. 

Although ultrasound (US) guidance has several expected advantages, there are few clinical studies to support the use of US guidance in clinical practice. In a 2007 literature review on the utility of facet injections, Sehgal et al. (9) state, "Ultrasound guided injections are used for regional blocks. There is interest in applying this technology in chronic pain. A few papers have described ultrasound guided facet joint and nerve injections in cadavers and human subjects. Some have attempted face validity studies by confirming needle placement with fluoroscopic or CT imaging. Although there are obvious benefits to using ultrasound guidance, there are insufficient data for critical analysis and conclusions."

In 2009, Narouze et al. (10) reported a feasibility study of a prospective series of 10 patients who received cervical nerve root transforaminal injections using US as the primary imaging tool, with fluoroscopic confirmation. The authors determined that US may facilitate identifying critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical nerve root injections. They concluded that a randomized controlled trial to compare the effectiveness and safety of US imaging against other imaging techniques seems warranted.

ClinicalTrials.gov currently lists a study on US guided cervical medial branch block (NCT00896688) (11); as of May 2012 this study has not yet begun recruitment. The study states that the diagnostic cervical branch block for neck pain due to cervical facet joint pain has been traditionally done under fluoroscopic guidance; its diagnostic value and technique have been well established. However, recently some studies have shown that the diagnostic cervical and lumbar medial branch block can be done under US guidance. The primary outcome is to determine the efficacy of the use of US for diagnostic cervical medial branch block on pain patients who have developed neck pain, cervicogenic headache, or shoulder pain.

A search of peer reviewed literature through May 2012 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies        

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
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
ICD-10 Codes

G89.29, G89.4, M54.2, M54.6, M54.89, M54.9

Procedural Codes: 64490, 64491, 64492, 64493, 64494, 64495, 77003, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T
References
  1. National Institutes of Health—National Institute of Neurological Disorders and Stroke:  Low Back pain Fact Sheet. Pub No. 03-5161 (2003 July).
  2. Bogduk, N. Practice guidelines for spinal diagnostic and treatment procedures. International Spine Intervention Society (2004):86-94.
  3. 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.
  4. 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)
  5. 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).
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Ultrasound Guided Diagnostic Cervical Medial Branch Block. Trial Identifier #00896688. McMaster University 2009. (Available at www.clinicaltrials.gov (accessed June 11, 2012).
History
March 2011  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. 
April 2012  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. 
December 2012 Policy updated with literature review through August 2012; reference numbers 10 and 33 added. Chemodenervation added to investigational policy statement.
April 2013 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.
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Facet Joint Injections