Facet Joint Interventions

This policy covers fluoroscopy/CT‑guided facet joint interventions—including diagnostic medial branch controlled blocks, therapeutic facet injections, and conventional medial branch radiofrequency neurotomy/denervation—for management of facet‑mediated spinal pain (e.g., chronic lumbar facet syndrome and cervical facet/neck pain, including post‑whiplash and degenerative facet disease). Coverage requires pain ≥3 months with failed conservative care within the past year (≥4 weeks PT or prescribed home exercise unless a synovial cyst with radiculopathy), diagnostic confirmation with up to two controlled medial branch blocks showing ≥80% relief for RFA (blocks must be at the same levels), procedures performed under fluoroscopy/CT by a physician, a maximum of three spinal levels treated per session and one invasive pain procedure per visit, and repeat RFA only after ≥6 months if prior treatment provided ≥50% relief for ≥6 months.

"Chronic low back pain attributed to disorders of the lumbar facet (zygapophyseal) joint."