Injection Series: Part II – Facet Joints (Paravertebral)

Paravertebral (spine)

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Facet Joint Injections
Facet joint injections are frequently used to diagnose and treat facet joint pain, also known as lumbar spondylosis or zygapophyseal joint pain. These injections, which include both anesthetic and corticosteroid medications, can offer relief for two to four months or more.

CMS LCD Coverage criteria:

Must meet ALL of the following criteria:

  1. Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale; AND*
  2. Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated), AND
  3. Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst), AND
  4. 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. A disability scale must also be obtained at baseline to be used for functional assessment (if patient qualifies for treatment).

Medicare’s top TPE denials for facet joint injections are as follows:

Medical Necessity –

  • The documentation lacked evidence to support the requirements of the Novitas Local Coverage Determination (LCD) because the documentation lacked pain level, prior conservative therapy and/or effectiveness of treatment.

Insufficient Documentation –

  • Documentation was not submitted to Novitas in a timely manner to support the services billed to Medicare.
  • Documentation submitted did not support the services that was billed on the claim.
  • Upon receipt of the additional development request, the provider deemed the service was billed in error to Medicare.

Frequency limitation: No more than four therapeutic facet joint injection sessions per covered spinal region will be reimbursed within a rolling 12-month period.

Injection Series:  Part III – Trigger Points

Resources:

Novitas TPE:  Facet Joint Injections and Checklist

CDI Facet Joint Injections Tip Sheet