GENERAL INFORMATION 
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Policy 

Note: Any injection performed at least two years from prior injections in the same region will be considered a new episode of care and the INITIAL injection requirements must be met for approval. Events such as surgery on the same spinal region or any new pathology would also prompt a new episode of care.

INDICATIONS FOR FACET JOINT INJECTIONS OR MEDIAL BRANCH NERVE BLOCKS^1,2,3,4:

To confirm non-radicular pain suggestive of facet joint or pars interarticularis origin ALL of the following must be met:

• History of mainly axial or non-radicular pain unless stenosis is caused by synovial cyst^5,6,7
• Lack of evidence that the primary source of pain being treated is from sacroiliac joint pain, discogenic pain, disc herniation, or radiculitis^5,6,7
• For chronic lumbar spondylolysis, imaging studies that confirm the presence of a pars interarticularis fracture/defect are required
• Pain causing functional disability or average pain level of ≥ 6 on a scale of 0 to 10^6,7,8 
• Duration of pain of at least 3 months^6,7
• Failure to respond to non-operative conservative therapy* targeting the requested spinal region for a minimum of 6 weeks in the last 6 months unless the medical reason this treatment cannot be done is clearly documented; OR details of engagement in ongoing non-operative conservative therapy* if the individual has had prior spinal injections in the same region^6,8,9

NOTE: All procedures must be performed under imaging guidance.^{10,11,12,13,14} 

INDICATIONS FOR REPEAT INJECTIONS
Facet joint injections and medial branch nerve blocks may be repeated only is considered MEDICALLY NECESSARY. Each injection requires an authorization, and the following criteria must be met for repeat injections: 

• Up to 2 injections may be performed in the initial diagnostic phase, no sooner than 2 weeks apart, provided at least 50% pain relief or significant documented functional improvement is obtained.⁶
  • If the most recent injection was a diagnostic block with local anesthetic only, there must be at least 7 days between injections.
• If the first injection is unsuccessful, a second injection may be performed at a different spinal level or with a change in technique (e.g., from an intra-articular facet injection to a medial branch nerve block) given there is a question about the pain generator or evidence of multi-level pathology.
• Facet joint injections may only be repeated after the initial diagnostic phase if the individual has had at least 50% pain relief or significant documented functional improvement for a minimum of 2 months after each therapeutic injection.⁶
• The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 to 10.^6,8
• The individual is engaged in ongoing active conservative therapy*, unless the medical reason this treatment cannot be done is clearly documented^6,8,9
  • Diagnostic injections within 1 month of the previous injection do not require documentation of ongoing active conservative therapy
• In the diagnostic phase, a maximum of 2 procedures may be performed. Repeat diagnostic injections after successful radiofrequency neurolysis are allowable if there is a question about the pain generator, different levels are to be targeted, or if there is surgery in the same spinal region.
• A maximum of 4 facet injections may be performed in a 12-month period per spinal region (except under unusual circumstances, such as a recurrent injury).⁶
  • Unilateral injections performed at the same level on the right vs. left within 1 month of each other would be considered as one procedure toward the total number of facet procedures allowed per 12 months.⁶
• If different spinal regions are being treated, injections should be administered at intervals of no sooner than 7 days unless a medical reason is provided to necessitate injecting multiple regions on the same date of service (see NOTE).⁶

Radiofrequency neurolysis procedures should be considered in individuals with a successful medial branch nerve block (at least 70% pain relief or improved ability to function), but with insufficient sustained relief (less than 2 – 3 months improvement).^6,8

NOTE: It is generally considered NOT MEDICALLY NECESSARY to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient). Different types of injections in the same spinal region (cervical, thoracic, or lumbar) should not be done on the same day with the exception of a facet injection and ESI performed during the same session for a synovial cyst confirmed on imaging. 

EXCLUSIONS
These requests are excluded from consideration under this guideline:

• Sacral lateral branch blocks (S1, S2, S3)
• Atlantoaxial joint injections (C1-2)
• Occipital nerve blocks
• Hardware injection or block for diagnosis or treatment of post-surgical or other spine pain

CONTRAINDICATIONS FOR FACET JOINT INJECTIONS

• Active systemic or spinal infection
• Skin infection at the site of needle puncture
• Inability to obtain percutaneous access to the target facet joint

Rationale
Facet joints, (also called zygapophyseal joints or z-joints), posterior to the vertebral bodies in the spinal column and connecting the vertebral bodies to each other, are located at the junction of the inferior articular process of a more cephalad vertebra and the superior articular process of a more caudal vertebra. These joints provide stability and enable movement, allowing the spine to bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.^6,18

Facet joints are clinically important spinal pain generators in individuals with chronic spinal pain. In 15% – 45% of individuals with chronic low back pain, facet joints have been implicated as a cause of the pain. Facet joints are considered as the cause of chronic spinal pain in 48% of individuals with thoracic pain and 54% – 67% of individuals with chronic neck pain.¹⁹ Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck, and shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome,’ a term originally used by Ghormley²⁰ in 1933, referring to back pain caused by pathology at the facet joints. Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting individuals for controlled local anesthetic blocks of either the medial branches or the facet joint itself.²¹ 

Medical necessity management for paravertebral facet injections includes an initial evaluation including history and physical examination and a psychosocial and functional assessment. The following must be determined: nature of the suspected organic problem; non-responsiveness to conservative treatment*; level of pain and functional disability; conditions which may be contraindications to paravertebral facet injections; and responsiveness to prior interventions.

The most common source of chronic pain is the spine, and up to 80% of the U.S. population suffers from spinal pain sometime during their life span.²² Facet joint interventions are used in the treatment of pain in certain individuals with a confirmed diagnosis of facet joint pain. Interventions include intraarticular injections and medial branch nerve blocks in the lumbar, cervical, and thoracic spine. Prior to performing this procedure, shared decision-making between patient and physician must occur, and the patient must understand the procedure and its potential risks and results. Facet joint injections or medial branch nerve blocks require guidance imaging. 

Definitions

*Conservative Therapy: Non-operative treatment should include a multimodality approach consisting of a combination of active and inactive components. Inactive components can include rest, ice, heat, modified activities, medical devices, acupuncture, stimulators, medications, injections, and diathermy. Active modalities should be region-specific (targeting the cervical, thoracic, or lumbar spine) and consist of physical therapy, a physician-supervised home exercise program**, or chiropractic care.^8,23

**Home Exercise Program (HEP): The following two elements are required to meet guidelines for completion of conservative therapy:

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor^23,24,25; AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises). Closure of medical offices, closure of therapy offices, patient inconvenience, or noncompliance without explanation does not constitute “inability to complete” HEP.^8,23

Terminology: Facet Injections; Facet Joint Blocks; Paravertebral Facet Injections; Paravertebral Facet Joint Injections; Paravertebral Facet Joint Nerve Injections; Zygapophyseal injections; Lumbar Facet Blockade; Medial Branch blocks

References

1. Wald JT, Geske JR, Diehn FE, et al. A practice audit of CT-guided injections of pars interarticularis defects in patients with axial low back pain: a primer for further investigation. Pain Med. May 2014;15(5):745-50. doi:10.1111/pme.12344
2. Kershen LM, Nacey NC, Patrie JT, Fox MG. Accuracy and efficacy of fluoroscopy-guided pars interarticularis injections on immediate and short-term pain relief. Skeletal Radiol. Oct 2016;45(10):1329-35. doi:10.1007/s00256-016-2427-2
3. Linton AA, Hsu WK. A Review of Treatment for Acute and Chronic Pars Fractures in the Lumbar Spine. Curr Rev Musculoskelet Med. Aug 2022;15(4):259-271. doi:10.1007/s12178-022-09760-9
4. Choi JH, Ochoa JK, Lubinus A, Timon S, Lee YP, Bhatia NN. Management of lumbar spondylolysis in the adolescent athlete: a review of over 200 cases. Spine J. Oct 2022;22(10):1628-1633. doi:10.1016/j.spinee.2022.04.011
5. Khan AM, Girardi F. Spinal lumbar synovial cysts. Diagnosis and management challenge. Eur Spine J. Aug 2006;15(8):1176-82. doi:10.1007/s00586-005-0009-4
6. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. Apr 2013;16(2 Suppl):S49-283. 
7. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. Jul-Aug 2009;12(4):699-802. 
8. Summers J. International Spine Intervention Society Recommendations for treatment of Cervical and Lumbar Spine Pain. 2013.
9. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain Med. Nov 26 2021;22(11):2443-2524. doi:10.1093/pm/pnab281
10. Weininger M, Mills JC, Rumboldt Z, Bonaldi G, Huda W, Cianfoni A. Accuracy of CT guidance of lumbar facet joint block. AJR Am J Roentgenol. Mar 2013;200(3):673-6. doi:10.2214/ajr.12.8829
11. Amrhein TJ, Joshi AB, Kranz PG. Technique for CT Fluoroscopy-Guided Lumbar Medial Branch Blocks and Radiofrequency Ablation. AJR Am J Roentgenol. Sep 2016;207(3):631-4. doi:10.2214/ajr.15.15694
12. Chen CPC, Chen JL, Ho CS, Suputtitada A. Ultrasound-guided Medial Branch Blocks, Facet Joint, and Multifidus Muscle Injections: How It Is Done under One Needle Insertion Point! Anesthesiology. Mar 2020;132(3):582-583. doi:10.1097/aln.0000000000003043
13. Han SH, Park KD, Cho KR, Park Y. Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain: A retrospective comparative study. Medicine (Baltimore). Apr 2017;96(16):e6655. doi:10.1097/md.0000000000006655
14. Park KD, Lim DJ, Lee WY, Ahn J, Park Y. Ultrasound versus fluoroscopy-guided cervical medial branch block for the treatment of chronic cervical facet joint pain: a retrospective comparative study. Skeletal Radiol. Jan 2017;46(1):81-91. doi:10.1007/s00256-016-2516-2
15. Spinal Injections. Washington State Health Care Authority. Updated May 20, 2016. Accessed September 22, 2022. http://hca.wa.gov/assets/program/spinal_injections-rr_final_findings_decision_060216.pdf
16. Health technology reviews: spinal injections. Washington State Health Care Authority. Updated 2022. Accessed September 22, 2022. http://hca.wa.gov/about-hca/programs-and-initiatives/health-technology-assessment/spinal-injections
17. About the Health Care Authority (HCA). Washington State Health Care Authority. Updated 2022. Accessed September 22, 2022. http://hca.wa.gov/about-hca
18. Kim BY, Concannon TA, Barboza LC, Khan TW. The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review. Diagnostics (Basel). Dec 9 2021;11(12)doi:10.3390/diagnostics11122311
19. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5:15-15. doi:10.1186/1471-2474-5-15
20. Ghormley RK. Low back pain: with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101(23):1773-1777. 
21. Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol. 2013;9(4):216-224. doi:10.1038/nrrheum.2012.199
22. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. May 2007;25(2):353-71. doi:10.1016/j.ncl.2007.01.004
23. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Apr 4 2017;166(7):514-530. doi:10.7326/m16-2367
24. Sculco AD, Paup DC, Fernhall B, Sculco MJ. Effects of aerobic exercise on low back pain patients in treatment. Spine J. Mar-Apr 2001;1(2):95-101. doi:10.1016/s1529-9430(01)00026-2
25. Durmus D, Unal M, Kuru O. How effective is a modified exercise program on its own or with back school in chronic low back pain? A randomized-controlled clinical trial. J Back  Musculoskelet Rehabil. 2014;27(4):553-61. doi:10.3233/bmr-140481

Coding Section

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. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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