CMM-201: Facet Joint Injections/Medial Branch Blocks

Covers initial and confirmatory diagnostic facet joint injections/medial branch blocks and limited subsequent therapeutic injections as an alternative to radiofrequency ablation, while excluding procedures without fluoroscopic/CT guidance, injections at posteriorly fused segments, >3 contiguous levels per session, same‑day other injections, injections for untreated radiculopathy (except synovial cysts), ultrasound/biologic injectates, and other listed exclusions. Coverage requires pain ≥3 months, ≥4 weeks of conservative therapy (unless contraindicated), clinical/imaging exclusion of other causes, documented ≥80% anesthetic relief for diagnostic blocks (confirmatory block at the same level if RFA is being considered), and therapeutic repeats only ≥6 months later with prior ≥50% relief for ≥12 weeks and documented ineligibility for RFA.

"Initial Diagnostic Facet Joint Injection/Medial Branch Block: "considered medically necessary to determine whether chronic neck or back pain is of facet joint origin when ALL of the following crite..."