Facet Joint Interventions for Pain Management

Indications and 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 local coverage determination LCD: Facet Joint Interventions for Pain Management (L33930) 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 CPT codes listed.

Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:

• 64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s))

• 64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s))

Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.

Documentation Requirements

Providers should include the following documentation with their Facet Joint Interventions PA request: 

• Clear plan of care of what is being requested
• History of present illness and recent physical exam including level specific findings
• Relevant diagnostic test results
• Procedure records as applicable
• Pain history to include valid scale, location, severity, and duration
• Evidence of failed conservative management
• Beneficiary response to prior facet joint interventions, 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

• Pain present for minimum of three months with documented failure to respond to noninvasive conservative management (as tolerated)

• 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.
• Pain assessment must be performed and documented at baseline, after each diagnostic procedure using the same pain scale for each assessment.

Requirements for the second confirmatory procedure:

• Meets requirements for the first diagnostic and

• After the first diagnostic procedure, there is at least 80% 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-weeks 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 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 medically reasonable and necessary diagnostic facet joint procedures with each one providing a minimum of 80% 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% consistent pain relief for at least three months from the prior therapeutic procedure or at least 50% 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 therapeutic facet joint injection (IA) sessions will be reimbursed per rolling 12 months.

Radiofrequency Ablation (RFA)/Denervation

RFA uses radio waves to stop medial branch nerves from transmitting pain signals from the injured facet joint to the brain; involves 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 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 are considered medically reasonable and necessary for patients who meet all the following criteria:

• Initial thermal RFA:
  • After the patient has had at least two medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used)

• Repeat thermal facet joint RFA:
  • RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs compared to baseline measurement using the same scale. 

The CPT codes for radiofrequency ablation (RFA)/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 RFA sessions over a 12-month rolling period. 

Billing/Coding Alerts

For more information related to billing and coding please refer to the local coverage article Billing and Coding: Facet Joint Interventions for Pain Management (A57787) 

Limitations/Contraindications

For more information related to limitations and contraindications please refer to the LCD: Facet Joint Interventions for Pain Management (L33930) 

Best Practice, Documentation Feedback, and Tips

The following are best practices, documentation feedback and tips related to facet joint interventions.

Coverage and Procedure Limitations:

• Thorough pain assessment surrounding all facet joint interventions should include four points: a pre-procedure pain score, a post-procedure pain score, the percentage of relief, and the duration of relief.
• Only one covered spinal region (cervical/thoracic or lumbar/sacral) may be treated during the same session.
• The policy allows a maximum of two unilateral or four bilateral per session (one spinal region allowed per session with 1-2 levels unilateral or bilateral per session).
• Facet joint procedures (injection and denervation) cannot be performed after anterior lumbar fusion (ALIF).
• For coverage purposes, the cervical and thoracic spine are considered one spinal region, and the lumbar and sacral spine are considered a second spinal region:
  • Cervical/Thoracic region = C1-C7/T1-T12
  • Lumbar/Sacral region = L1-L5/S1-S5
• Review the LCD and billing and coding article for more information.
• Facet joint interventions are typically performed using local anesthetic. Moderate sedation, deep sedation, and general anesthesia are generally not considered medically reasonable and necessary.
• The RFA can be performed unilaterally or bilaterally in the same session depending on what is clinically indicated. The session limit is two sessions per twelve months regardless of whether it was performed unilaterally or bilaterally.
• Degenerative findings on imaging do not by themselves identify the source of pain. Documentation should support the facet joint as the suspected pain generator before intervention is performed.
• Following a previously successful RFA, repeat diagnostic injections are not routinely required unless there is uncertainty regarding the source of recurrent pain.
• Non-thermal modalities for facet joint denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and cryoablation (COOLIEF) are considered not medically reasonable and necessary.

Billing and Coding:

• Providers should follow the Billing and Coding: Facet Joint Interventions for Pain Management (A57787) for code selection involving the T12-L1 and L1-L2 levels, including applicable bilateral billing requirements.
  • For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use CPT codes 64490 and 64494 once.
  • For bilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use CPT code 64490 with modifier 50 and CPT code 64494 with modifier 50.
• Procedures exceeding Medicare coverage limitations may be billed in accordance with ABN requirements when all Medicare beneficiary notification requirements are met. For example, if the patient still wants the 3rd level injected in the same region knowing the 3rd level is noncovered per policy.
• Bilateral facet joint procedures should be reported with modifier 50 in accordance with CPT coding instructions and applicable Medically Unlikely Edits (MUE) requirements. Indicate the levels/laterality/the use of any modifiers on the coversheet submitted with each prior authorization request (PAR).

References

• Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
• LCD: Facet Joint Interventions for Pain Management (L33930)
• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
• Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide