HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
Z-61-019
Topic:
Facet Joint Injections/Medial Branch Blocks
Section:
Miscellaneous
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
September 2018
Annual Review:
April 2018
 
 

Facet Joint Injections/medial branch blocks refer to the injection of local anesthetic and possibly a corticosteroid in the facet joint capsule or along the nerves supplying the facet joints from C2-3 to L5-S1. The injection/block applies directly to the facet joint(s) blocked and not to the number of nerves blocked that innervate the facet joint(s). Even though either procedure can be used to diagnose facet joint pain, a medial branch block is generally considered more appropriate. A diagnostic facet joint injection/medial branch block is considered positive when there is at least 80% pain relief for the duration of the effect of the local anesthetic used.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

An initial diagnostic facet joint injection/medial branch block may be considered medically necessary to determine whether chronic neck or back pain is of facet joint origin when ALL of the following criteria are met:

·         Pain is exacerbated by facet loading maneuvers on physical examination; and

·         Pain has persisted despite at least four weeks of appropriate conservative treatment (i.e., physical methods including physical therapy, chiropractic care and exercise, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or analgesics) unless contraindicated and the reason(s) for contraindication(s) is/are documented in the medical record; and

·         Clinical findings and imaging studies suggest no other obvious cause of the pain (i.e., central spinal stenosis with neurogenic claudication/myelopathy, foraminal stenosis or disc herniation with concordant radicular pain/radiculpathy, infection, tumor, fracture, pseudoarthrosis, pain related to spinal instrumentation); and

·         The spinal motion segment is not posteriorly fused.

A second diagnostic facet joint injection/medial branch block, performed to confirm the validity of the clinical response to the initial facet joint injection, may be considered medically necessary when ALL of the following criteria are met:

·         Administered at the same level as the initial block; and

·         The initial diagnostic facet joint injection produced a positive response (i.e., at least 80% pain relief for the duration of the effect of the local anesthetic); and

·         A radiofrequency joint denervation/ablation procedure is being considered

An intra-articular facet joint injection performed with synovial cyst aspiration, in addition to a transforaminal epidural steroid injection, may be considered medically necessary when the following criteria are met:

·         Advanced diagnostic imaging studies (e.g., MRI, CT, CT myelogram) confirm compression or displacement of the corresponding nerve root by a facet joint synovial cyst; and

·         Clinical correlation with the individual’s signs and symptoms of radicular pain or radiculopathy, based on history and physical examination.

Performance of a facet joint injection/medial branch block is considered not medically necessary when performed for ANY of the following indications:

·         Without the use of fluoroscopic or CT guidance

·         In the presence of an untreated radiculopathy

·         When a radiofrequency joint denervation/ablation procedure (i.e., facet neurotomy, facet rhizotomy) is not being considered

·         The facet joint injection is performed at a fused posterior spinal motion segment

·         On the same day of service when performing other injections (e.g., epidural steroid, sacroiliac) in the same region

·         Performance of injections/blocks on more than three (3) joint levels

·         Additional diagnostic facet joint injection/medial branch blocks at the same level(s) as a prior successful radiofrequency denervation/ablation procedure

Performance of a facet joint injection/medial branch block is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature, when performed for ANY of the following indications:

·         Unless performed as a second confirmatory block, all injections subsequent to the initial injection (i.e., therapeutic injections); or

·         When performed under ultrasound guidance

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Related Policies


Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Facet Joint Injections/Medial Branch Blocks is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.