Medical policy: Facet Joint Injections and Medial Branch Blocks

Número de política: MP 4.050

Beneficio clínico

  • Minimizar el riesgo o la preocupación de seguridad.
  • Minimizar las intervenciones dañinas o ineficaces.
  • Garantizar el nivel de atención adecuado.
  • Asegurar la duración adecuada del servicio para las intervenciones.
  • Asegurar que se hayan cumplido los requisitos médicos recomendados.
  • Asegurar el lugar apropiado para el tratamiento o servicio.

Fecha de entrada en vigor: 5/1/2026

Política

Note: Documentation of the usage of validated patient-focused pain intensity assessment scales (such as Numeric Rating Scales, Visual Analog Scales, Verbal Rating Scales, the Faces Pain Scale, or the Pain Thermometer) is considered medically necessary when determining different levels of pain sensation during medical management.

Facet joint injections/medial branch blocks

Initial diagnostic facet joint injection/medial branch block

Facet joint injections/medial branch blocks may be considered medically necessary for lumbar or cervical pain lasting more than 3 months, despite appropriate conservative treatment, as a diagnostic procedure to determine whether the pain is of facet joint origin.

Second diagnostic facet joint injection/medial branch block

A second diagnostic facet joint injection/medial branch block may be considered medically necessary when all the following criteria are met:

  • The initial diagnostic injection was successful at relieving pain (see Policy Guidelines); and
  • The second diagnostic injection will be administered at the same level(s) as the initial diagnostic block; and
  • Radiofrequency joint denervation is being considered.

Therapeutic facet joint injection/medial branch block

Therapeutic facet joint injections/medial branch blocks may be considered medically necessary when all the following criteria are met:

  • There is documented successful response to at least 2 sequential diagnostic facet joint injections/medial branch blocks at the same level(s); and
  • The individual is not a candidate for radiofrequency joint denervation; and
  • For subsequent therapeutic blocks there was a successful response to the prior therapeutic injection for at least 3 months’ duration; and
  • For each spinal region, a maximum of 4 therapeutic facet joint sessions are medically necessary in a 12-month period.

Facet joint injection/medial branch block, diagnostic or therapeutic, for any indication other than the ones listed above is considered investigational. No hay pruebas suficientes para apoyar una conclusión general con respecto a los resultados o beneficios para la salud asociados con este procedimiento.

Ultrasound guidance for facet joint injections is considered investigational. No hay pruebas suficientes para apoyar una conclusión general con respecto a los resultados o beneficios para la salud asociados con este procedimiento.

Directrices de la política

Facet joint injections/medial branch blocks

Conservative therapies may include medications (e.g., nonsteroidal anti-inflammatory drugs, antidepressants), physical treatments (exercise, heat or cold therapy, massage, physical therapy), integrative treatments (acupuncture, spinal manipulation if indicated), and others (nutrition, weight loss, sleep hygiene).

A successful block refers to a sustained meaningful reduction in pain. This is subjective but often defined as a 20-point improvement on a 0-to-100 visual analog scale or a 50% improvement using a validated scale.

Referencias cruzadas

  • MP 4.014 Epidural steroid injections for back pain
  • MP 5.049 Facet joint denervation

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Refer to the FEP medical policy manual. The FEP medical policy manual can be found at FEP Medical Policy Manual.

Descripción/antecedentes

Facet joint injections/medial branch blocks

Facet joint injections, also known as intra-articular injections (IA), are a minimally invasive procedure in which a physician injects a small amount of anesthetic, which may or may not contain a steroid, to numb the facet joint. An appropriately performed IA facet joint injection, in which the medication is only distributed to the joint capsule, can help to diagnose facet joint pain. If the pain goes away after the IA injection, or is significantly decreased, then the facet joint can be determined to be the source of pain. While a good diagnostic tool for facet-mediated pain, IA is less predictive than medial branch blocks to medial branch radiofrequency ablation.

Medial branch blocks (MBB) are also used to diagnose facet joint pain and may or may not contain a steroid. MBB may not achieve the level of specificity that an appropriately performed IA injection can. This is due to the fact that the medial branch is not encapsulated, and the medication can result in anesthesia of not only the medial branch, but also anesthesia of other nerves in close proximity. This could potentially result in non-selective neural blockade and a false-positive result. Even though this is a known possibility, MBB is an acceptable diagnostic test, and it is usually the preferred test when lumbar facet radiofrequency ablation is being considered. When used as a tool before lumbar facet neurolysis, MBB may be associated with a higher success rate than IA injections.

Once the facet joint has been determined to be the source of pain, a series of injections may be needed to establish consistency of results, especially if diagnostic facet joint injections/medial branch blocks are followed by neurolysis.

Image guidance has become an essential component of performing spinal procedures in pain management. For MBB and IA facet joint injections, fluoroscopy and to a lesser degree CT guidance are most commonly used. The use of imaging allows accurate needle placement ensuring the lowest volume of anesthetic is administered, thereby reducing spread to surrounding tissues which may lead to false-positive results. Image guidance also improves safety as it helps to avoid unnecessary injury.

Fundamento

For individuals who have back or neck pain who receive facet joint injections/medial branch blocks, the clinical evidence for the efficacy of these injections is considered limited. Based on consensus practice guidelines and standards of care for those in chronic pain, the evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Definiciones

Facet joint refers to one of the zygapophyseal joints of the vertebral column between the articulating facets of each pair of vertebrae.

Nerve block refers to interruption of the conduction of impulses to peripheral nerves or nerve trunks by the injection of a local anesthetic solution.

Numeric pain rating scale: A pain assessment system in which patients are asked to rate their pain on a scale from 1 to 10, with 10 representing the worst pain they have experienced or could imagine.

Visual analog scale (VAS): A graphic scale that helps a patient to quantify pain, depression, and other subjective and otherwise unmeasurable states or conditions.

Zygapophyseal concerns a zygapophysis, one of the articular processes of a neural arch of a vertebra.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios del miembro, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: Es posible que esta lista de códigos no sea exhaustiva y que los códigos estén sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Investigational; therefore, not covered, ultrasound guidance for facet joint injections

Procedure codes

0213T

0214T

0215T

0216T

0217T

0218T

 

 

 

 

Cubierto cuando es médicamente necesario

Procedure codes

64490

64491

64492

64493

64494

64495

 

 

 

 
Códigos de diagnóstico de la CIE-10-MC
Descripción

G54.1

Lumbosacral plexus disorders

G54.2

Cervical root disorders, not elsewhere classified

G54.3

Thoracic root disorders, not elsewhere classified

G54.4

Lumbosacral root disorders, not elsewhere classified

M08.1

Juvenile ankylosing spondylitis

M43.22

Fusion of spine, cervical region

M43.23

Fusion of spine, cervicothoracic region

M43.24

Fusion of spine, thoracic region

M43.25

Fusion of spine, thoracolumbar region

M43.26

Fusion of spine, lumbar region

M43.27

Fusion of spine, lumbosacral region

M43.28

Fusion of spine, sacral and sacrococcygeal region

M45.0

Ankylosing spondylitis of multiple sites in spine

M45.2

Ankylosing spondylitis of cervical region

M45.3

Ankylosing spondylitis of cervicothoracic region

M45.4

Ankylosing spondylitis of thoracic region

M45.5

Ankylosing spondylitis of thoracolumbar region

M45.6

Ankylosing spondylitis of lumbar region

M45.7

Ankylosing spondylitis of lumbosacral region

M45.8

Ankylosing spondylitis of sacral and sacrococcygeal region

M45.A0

Non-radiographic axial spondyloarthritis of unspecified sites in spine

M45.A1

Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region

M45.A2

Non-radiographic axial spondyloarthritis of cervical region

M45.A3

Non-radiographic axial spondyloarthritis of cervicothoracic region

M45.A4

Non-radiographic axial spondyloarthritis of thoracic region

M45.A5

Non-radiographic axial spondyloarthritis of thoracolumbar region

M45.A6

Non-radiographic axial spondyloarthritis of lumbar region

M45.A7

Non-radiographic axial spondyloarthritis of lumbosacral region

M45.A8

Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region

M45.AB

Non-radiographic axial spondyloarthritis of multiple sites in spine

M46.02

Spinal enthesopathy, cervical region

M46.03

Spinal enthesopathy, cervicothoracic region

M46.04

Spinal enthesopathy, thoracic region

M46.05

Spinal enthesopathy, thoracolumbar region

M46.06

Spinal enthesopathy, lumbar region

M46.07

Spinal enthesopathy, lumbosacral region

M46.08

Spinal enthesopathy, sacral and sacrococcygeal region

M46.09

Spinal enthesopathy, multiple sites in spine

M46.1

Sacroiliitis, not elsewhere classified

M47.012

Anterior spinal artery compression syndromes, cervical region

M47.013

Anterior spinal artery compression syndromes, cervicothoracic region

M47.014

Anterior spinal artery compression syndromes, thoracic region

M47.015

Anterior spinal artery compression syndromes, thoracolumbar region

M47.016

Anterior spinal artery compression syndromes, lumbar region

M47.022

Vertebral artery compression syndromes, cervical region

M47.12

Other spondylosis with myelopathy, cervical region

M47.13

Other spondylosis with myelopathy, cervicothoracic region

M47.14

Other spondylosis with myelopathy, thoracic region

M47.15

Other spondylosis with myelopathy, thoracolumbar region

M47.16

Other spondylosis with myelopathy, lumbar region

M47.22

Other spondylosis with radiculopathy, cervical region

M47.23

Other spondylosis with radiculopathy, cervicothoracic region

M47.24

Other spondylosis with radiculopathy, thoracic region

M47.25

Other spondylosis with radiculopathy, thoracolumbar region

M47.26

Other spondylosis with radiculopathy, lumbar region

M47.27

Other spondylosis with radiculopathy, lumbosacral region

M47.28

Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M47.812

Spondylosis without myelopathy or radiculopathy, cervical region

M47.813

Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.814

Spondylosis without myelopathy or radiculopathy, thoracic region

M47.815

Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.816

Spondylosis without myelopathy or radiculopathy, lumbar region

M47.817

Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.818

Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

M47.892

Other spondylosis, cervical region

M47.893

Other spondylosis, cervicothoracic region

M47.894

Other spondylosis, thoracic region

M47.895

Other spondylosis, thoracolumbar region

M47.896

Other spondylosis, lumbar region

M47.897

Other spondylosis, lumbosacral region

M47.898

Other spondylosis, sacral and sacrococcygeal region

M48.02

Spinal stenosis, cervical region

M48.03

Spinal stenosis, cervicothoracic region

M48.04

Spinal stenosis, thoracic region

M48.05

Spinal stenosis, thoracolumbar region

M48.061

Spinal stenosis, lumbar region without neurogenic claudication

M48.062

Spinal stenosis, lumbar region with neurogenic claudication

M48.07

Spinal stenosis, lumbosacral region

M48.08

Spinal stenosis, sacral and sacrococcygeal region

M48.8X2

Other specified spondylopathies, cervical region

M48.8X3

Other specified spondylopathies, cervicothoracic region

M48.8X4

Other specified spondylopathies, thoracic region

M48.8X5

Other specified spondylopathies, thoracolumbar region

M48.8X6

Other specified spondylopathies, lumbar region

M48.8X7

Other specified spondylopathies, lumbosacral region

M48.8X8

Other specified spondylopathies, sacral and sacrococcygeal region

M50.01

Cervical disc disorder with myelopathy, high cervical region

M50.021

Cervical disc disorder at C4-C5 level with myelopathy

M50.022

Cervical disc disorder at C5-C6 level with myelopathy

M50.023

Cervical disc disorder at C6-C7 level with myelopathy

M50.03

Cervical disc disorder with myelopathy, cervicothoracic region

M50.11

Cervical disc disorder with radiculopathy, high cervical region

M50.121

Cervical disc disorder at C4-C5 level with radiculopathy

M50.122

Cervical disc disorder at C5-C6 level with radiculopathy

M50.123

Cervical disc disorder at C6-C7 level with radiculopathy

M50.13

Cervical disc disorder with radiculopathy, cervicothoracic region

M50.21

Other cervical disc displacement, high cervical region

M50.221

Other cervical disc displacement at C4-C5 level

M50.222

Other cervical disc displacement at C5-C6 level

M50.223

Other cervical disc displacement at C6-C7 level

M50.23

Other cervical disc displacement, cervicothoracic region

M50.31

Other cervical disc degeneration, high cervical region

M50.321

Other cervical disc degeneration at C4-C5 level

M50.322

Other cervical disc degeneration at C5-C6 level

M50.323

Other cervical disc degeneration at C6-C7 level

M50.33

Other cervical disc degeneration, cervicothoracic region

M50.81

Other cervical disc disorders, high cervical region

M50.821

Other cervical disc disorders at C4-C5 level

M50.822

Other cervical disc disorders at C5-C6 level

M50.823

Other cervical disc disorders at C6-C7 level

M50.83

Other cervical disc disorders, cervicothoracic region

M51.04

Intervertebral disc disorders with myelopathy, thoracic region

M51.05

Intervertebral disc disorders with myelopathy, thoracolumbar region

M51.06

Intervertebral disc disorders with myelopathy, lumbar region

M51.14

Intervertebral disc disorders with radiculopathy, thoracic region

M51.15

Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16

Intervertebral disc disorders with radiculopathy, lumbar region

M51.17

Intervertebral disc disorders with radiculopathy, lumbosacral region

M51.24

Other intervertebral disc displacement, thoracic region

M51.25

Other intervertebral disc displacement, thoracolumbar region

M51.26

Other intervertebral disc displacement, lumbar region

M51.27

Other intervertebral disc displacement, lumbosacral region

M51.34

Other intervertebral disc degeneration, thoracic region

M51.35

Other intervertebral disc degeneration, thoracolumbar region

M51.360

Other intervertebral disc degeneration, lumbar region with discogenic back pain only

M51.361

Other intervertebral disc degeneration, lumbar region with lower extremity pain only

M51.362

Other intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain

M51.369

Other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain

M51.370

Other intervertebral disc degeneration, lumbosacral region with discogenic back pain only

M51.371

Other intervertebral disc degeneration, lumbosacral region with lower extremity pain only

M51.372

Other intervertebral disc degeneration, lumbosacral region with discogenic back pain and lower extremity pain

M51.379

Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain

M51.84

Other intervertebral disc disorders, thoracic region

M51.85

Other intervertebral disc disorders, thoracolumbar region

M51.86

Other intervertebral disc disorders, lumbar region

M51.87

Other intervertebral disc disorders, lumbosacral region

M53.2X7

Spinal instabilities, lumbosacral region

M53.2X8

Spinal instabilities, sacral and sacrococcygeal region

M53.3

Sacrococcygeal disorders, not elsewhere classified

M53.82

Other specified dorsopathies, cervical region

M53.83

Other specified dorsopathies, cervicothoracic region

M53.84

Other specified dorsopathies, thoracic region

M53.85

Other specified dorsopathies, thoracolumbar region

M53.86

Other specified dorsopathies, lumbar region

M53.87

Other specified dorsopathies, lumbosacral region

M53.88

Other specified dorsopathies, sacral and sacrococcygeal region

M54.2

Cervicalgia

M54.31

Sciatica, right side

M54.32

Sciatica, left side

M54.41

Lumbago with sciatica, right side

M54.42

Lumbago with sciatica, left side

M54.5

Dolor lumbar

M54.50

Low back pain, unspecified

M54.51

Vertebrogenic low back pain

M54.59

Other low back pain

M54.6

Pain in thoracic spine

M54.89

Other dorsalgia

M62.830

Muscle spasm of back

M62.85

Dysfunction of the multifidus muscles, lumbar region

M96.1

Post-laminectomy syndrome, not elsewhere classified

M99.21

Subluxation stenosis of neural canal of cervical region

M99.22

Subluxation stenosis of neural canal of thoracic region

M99.23

Subluxation stenosis of neural canal of lumbar region

M99.24

Subluxation stenosis of neural canal of sacral region

M99.31

Osseous stenosis of neural canal of cervical region

M99.32

Osseous stenosis of neural canal of thoracic region

M99.33

Osseous stenosis of neural canal of lumbar region

M99.34

Osseous stenosis of neural canal of sacral region

M99.41

Connective tissue stenosis of neural canal of cervical region

M99.42

Connective tissue stenosis of neural canal of thoracic region

M99.43

Connective tissue stenosis of neural canal of lumbar region

M99.44

Connective tissue stenosis of neural canal of sacral region

M99.51

Intervertebral disc stenosis of neural canal of cervical region

M99.52

Intervertebral disc stenosis of neural canal of thoracic region

M99.53

Intervertebral disc stenosis of neural canal of lumbar region

M99.54

Intervertebral disc stenosis of neural canal of sacral region

M99.61

Osseous and subluxation stenosis of intervertebral foramina of cervical region

M99.62

Osseous and subluxation stenosis of intervertebral foramina of thoracic region

M99.63

Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.64

Osseous and subluxation stenosis of intervertebral foramina of sacral region

M99.71

Connective tissue and disc stenosis of intervertebral foramina of cervical region

M99.72

Connective tissue and disc stenosis of intervertebral foramina of thoracic region

M99.73

Connective tissue and disc stenosis of intervertebral foramina of lumbar region

M99.74

Connective tissue and disc stenosis of intervertebral foramina of sacral region

S13.4XXA

Sprain of ligaments of cervical spine, initial encounter

S13.4XXD

Sprain of ligaments of cervical spine, subsequent encounter

S13.8XXA

Sprain of joints and ligaments of other parts of neck, initial encounter

S13.8XXD

Sprain of joints and ligaments of other parts of neck, subsequent encounter

S14.2XXA

Injury of nerve root of cervical spine, initial encounter

S14.2XXD

Injury of nerve root of cervical spine, subsequent encounter

S16.1XXA

Strain of muscle, fascia and tendon at neck level, initial encounter

S16.1XXD

Strain of muscle, fascia and tendon at neck level, subsequent encounter

S23.3XXA

Sprain of ligaments of thoracic spine, initial encounter

S23.3XXD

Sprain of ligaments of thoracic spine, subsequent encounter

S24.2XXA

Injury of nerve root of thoracic spine, initial encounter

S24.2XXD

Injury of nerve root of thoracic spine, subsequent encounter

S33.5XXA

Sprain of ligaments of lumbar spine, initial encounter

S33.5XXD

Sprain of ligaments of lumbar spine, subsequent encounter

S33.6XXA

Sprain of sacroiliac joint, initial encounter

S33.6XXD

Sprain of sacroiliac joint, subsequent encounter

S33.8XXA

Sprain of other parts of lumbar spine and pelvis, initial encounter

S33.8XXD

Sprain of other parts of lumbar spine and pelvis, subsequent encounter

S34.21XA

Injury of nerve root of lumbar spine, initial encounter

S34.21XD

Injury of nerve root of lumbar spine, subsequent encounter

S34.22XA

Injury of nerve root of sacral spine, initial encounter

S34.22XD

Injury of nerve root of sacral spine, subsequent encounter

S34.4XXA

Injury of lumbosacral plexus, initial encounter

S34.4XXD

Injury of lumbosacral plexus, subsequent encounter

Referencias

  1. American College of Occupational and Environmental Medicine. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery of workers. 2nd ed. Beverly Farms, MA: OEM Press; 2004: pp. 300 and 309.
  2. Boswell MV, Colson JD, Sehgal N, Dunbar EE, et al. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229-253.
  3. Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7-111.
  4. Capital Blue Cross integrated low back pain clinical practice guidelines. 4/1/11.
  5. Chou R. Subacute and chronic low back pain: nonsurgical interventional treatment. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated June 10, 2021. Literature review current through October 2023.
  6. Manchikanti L, Singh V, Falco FJ, et al. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial. Clin Trial NCT00355914. Pain Physician. 2008 Mar-Apr;11(2):121-132.
  7. Novitas Solutions Local Coverage Determination (LCD) L34892: facet joint interventions for pain management.
  8. Sehgal N, Dunbar EE, Shah RV, Colson J. Systematic review of diagnostic utility of facet (zygapophyseal) joint injections in chronic spinal pain: an update. Pain Physician. 2007;10(1):213-228.
  9. Adiji, Salahadin. Complex regional pain syndrome in adults: treatment, prognosis, and prevention. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated July 1, 2022.
  10. Speed CA. Injection therapies for soft-tissue lesions. Best Pract Res Clin Rheumatol. 2007;21(2):333-347.
  11. Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001824.
  12. North American Spine Society (NASS). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of low back pain. 2020. Available at Low Back Pain Guidelines.
  13. Won HS, Yang M, Kim VD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul). 2020;15(1):8-18. doi:10.17085/apm.2020.15.1.8
  14. Cohen SP, Moon JY, Brummett CM, White RL, Larkin TM. Medial branch blocks or intra-articular injections as a prognostic tool before lumbar facet radiofrequency denervation: a multicenter, case-control study. Reg Anesth Pain Med. 2015;40(4):376-383. doi:10.1097/AAP.0000000000000229
  15. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020;45(6):424-467. doi:10.1136/rapm-2019-101243

Antecedentes de la política

MP 4.050

11/18/2025 Major review. Facet joint injections/medial branch block indications and procedure codes taken from MP 4.014 and placed into this new policy.