GENERAL INFORMATION 

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Special Note

• Any injection performed at least two years from prior injections in the same region will be considered a new episode of care and the INITIAL injection requirements must be met for approval. Events such as surgery on the same spinal region or any new pathology would also prompt a new episode of care.
• Unilateral injections performed at the same level on the right vs. left within 1 month of each other would be considered as one procedure toward the total number of facet procedures allowed per 12 months.

Policy 
INDICATIONS FOR FACET JOINT INJECTIONS OR MEDIAL BRANCH NERVE BLOCKS
Facet Joint Pain⁽¹⁾
To confirm non-radicular pain suggestive of facet joint or pars interarticularis origin, ALL the following must be met:

• Pain that:
  • Is causing functional disability or average pain level of ≥ 6 (scale of 0 to 10) related to the requested spinal region
  • Duration for at least 3 months
  • Is either:
    • By history, mainly axial or non-radicular
    • Is radicular due to stenosis caused by synovial cyst (confirmed on imaging)⁽²⁾
  • Is of primary source that is not sacroiliac joint pain, discogenic pain, disc herniation, or radiculitis
• If diagnosed chronic lumbar spondylolysis
  • Imaging studies confirming the presence of a pars interarticularis fracture/defect are required.
• Failure to respond to non-operative conservative treatment* targeting the requested spinal region for a minimum of six (6) weeks in the last six (6) months unless the medical reason this treatment cannot be done is clearly documented 
  • Failure of conservative treatment is defined as one of the following:
    • Lack of meaningful improvement after a full course of treatment; OR
    • Progression or worsening of symptoms during treatment; OR
    • Documentation of a medical reason the member is unable to participate in the treatment (Closure of medical or therapy offices, patient inconvenience, or noncompliance without explanation does not constitute ‘inability to complete’ treatment)
  • OR details of engagement in ongoing non-operative conservative treatment* if the individual has had prior spinal injections in the same region

Imaging Guidance^(3–5)

• ALL procedures must be performed under imaging guidance.
  • The facet joint is commonly identified under image guidance by Computed tomography (CT) or Fluoroscopy. Medial Branch Blocks are commonly identified by Fluoroscopy. Ultrasound guidance can be an effective alternative if CT or fluoroscopy guided techniques are contraindicated; however, individual patient factors such as poor visualization due to deeper tissue layers e.g., increased Body Mass Index (BMI) may contribute to substandard image resolution.

Repeat Injections^(1,6)
Facet joint injections and medial branch nerve blocks may be repeated only as MEDICALLY NECESSARY. Injections performed on different days of service require separate authorization, and the following criteria must be met for repeat injections: 

Initial Treatment Phase

• Up to 2 diagnostic injections may be performed in the initial diagnostic phase, no sooner than 2 weeks apart:
  • At the same level, provided at least 50% pain relief or significant documented functional improvement is obtained OR
  • a second diagnostic injection may be performed at a different spinal level or with a change in technique (e.g., from an intra-articular facet injection to a medial branch nerve block) if:
    • there is a question about the pain generator or evidence of multi-level pathology AND
    • the first diagnostic injection was unsuccessful at achieving any pain relief.
  • If the most recent injection was a diagnostic block with local anesthetic only, there must be at least 7 days between injections.

Therapeutic Phase

• Facet joint injections may only be repeated after the initial diagnostic phase if:
  • It is an initial therapeutic injection subsequent to a successful initial treatment phase that provided at least 50% relief or functional improvement.
  • the individual has had at least 50% pain relief or significant documented functional improvement for a minimum of 2 months before each repeat therapeutic injection. 
  • The individual continues to have pain causing functional disability or average pain level ≥ 6 on a scale of 0 to 10 related to the requested spinal region. 
  • The individual is engaged in ongoing active conservative treatment* unless the medical reason this treatment cannot be done is clearly documented⁽⁷⁾
    • Diagnostic injections within 1 month of the previous injection do not require documentation of ongoing active conservative therapy.
• In the diagnostic phase, a maximum of 2 procedures may be performed. Repeat diagnostic injections after prior radiofrequency neurolysis are approvable if there is a question about the pain generator, different levels are to be targeted, or if there is surgery in the same spinal region. 
• A maximum of 4 facet injections may be performed in a 12-month period per spinal region (except under unusual circumstances, such as a recurrent injury) 
• If different spinal regions are being treated, injections should be administered at intervals of no sooner than 7 days unless a medical reason is provided to necessitate injecting multiple regions on the same date of service (see MEDICALLY NECESSARY)

NOTE: Radiofrequency ablation (RFA) procedures should be considered in individuals with a successful medial branch nerve block (at least 70% pain relief or improved ability to function), but with insufficient sustained relief (less than 2-3 months improvement). RFA cannot be performed on patients who have received an intra-articular joint injection instead of diagnostic medial branch blocks.

EXCLUSIONS
These requests are excluded from consideration:
Sacral lateral branch blocks (S1, S2, S3)

• Atlantoaxial joint injections (C1-2)
• Occipital nerve blocks
• Hardware injection or block for diagnosis or treatment of post-surgical or other spine pain

CONTRAINDICATIONS⁽³⁾
Although there are no absolute contraindications there are relative contraindications that include:

• Active systemic or spinal infection
• Skin infection at the site of needle puncture
• Inability to obtain percutaneous access to the target facet joint.
• Medication or contrast agent allergy

Rationale
Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck, and shoulders.

Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting individuals for controlled local anesthetic blocks of either the medial branches or the facet joint itself. 

Facet joint interventions include intraarticular injections and medial branch nerve blocks in the lumbar, cervical, and thoracic spine. Prior to performing this procedure, shared decision-making between patient and physician must occur, and the patient must understand the procedure and its potential risks and results. Facet joint injections or medial branch nerve blocks require guidance imaging.

Medical Necessity
Medical necessity management for paravertebral facet interventions include an initial evaluation including history and physical examination and a psychosocial and functional assessment. The following must also be determined⁽¹⁾:

• Nature of the suspected organic problem
• Non-responsiveness to conservative treatment*
• Level of pain and functional disability
• Conditions which may be contraindications to paravertebral facet injections
• Responsiveness to prior interventions

It is generally considered not medically necessary to perform multiple interventional pain procedures on the same date of service. Documentation of a medical reason to perform injections in different regions on the same day can be provided and will be considered on a case-by-case basis (e.g., holding anticoagulation therapy on two separate dates creates undue risk for the patient). Different types of injections in the same spinal region (cervical, thoracic, or lumbar) should not be done on the same day with the exception of a facet injection and ESI performed during the same session for a synovial cyst confirmed on imaging.

Conservative Treatment*⁽⁶⁾
Non-operative treatment should include a multimodality approach consisting of at least one (1) active and one (1) inactive component targeting the affected spinal region.

• Active components
  • Physical Therapy
  • Physician-supervised home exercise program**
  • Chiropractic Care
• Inactive Modalities
  • Medications (e.g., NSAIDs, steroids, analgesics)
  • Injections (e.g., epidural steroid injection, selective nerve root block)
  • Medical Devices (e.g., TENS unit, bracing)

Home Exercise Program (HEP)**⁽⁸⁾
The following two elements are required to meet conservative therapy guidelines for HEP: 

• Documentation of an exercise prescription/plan provided by a physician, physical therapist, or chiropractor AND
• Follow-up documentation regarding completion of HEP after the required 6-week timeframe or inability to complete HEP due to a documented medical reason (e.g., increased pain or inability to physically perform exercises).

SUMMARY OF EVIDENCE
Consensus Practice Guidelines on Interventions for Lumbar Facet Joint Pain⁽⁶⁾
Study Design:

• Multispecialty, international working group developed consensus guidelines.
• Modified Delphi method for consensus; literature review included MEDLINE, Embase, Google Scholar, Cochrane.
• Evidence graded using US Preventive Services Task Force criteria (Grades A–D, I statement; certainty: High, Moderate, Low).

Target Population:

• Adults with suspected lumbar facetogenic pain, especially those considered for lumbar facet blocks or radiofrequency ablation (RFA).

Key Factors:

• Prevalence: Wide range (4.8%–>50%) due to diagnostic variability.
• Guideline Scope: Addressed 17 clinical questions (diagnosis, imaging, conservative care, procedural technique, complications).
• Findings:
  • No pathognomonic clinical signs; physical exam and history have low sensitivity but some specificity (e.g., Revel’s criteria).
  • Imaging (SPECT) has moderate evidence for identifying painful joints before medial branch blocks (MBB); MRI/CT less useful.
  • Conservative care (PT, medications) recommended for ≥3 months before interventions.
  • Fluoroscopy is gold standard for guidance; ultrasound feasible in select cases.
  • MBB preferred over intra-articular (IA) injections for RFA selection; IA injections reserved for specific populations.
  • Sedation increases false-positive rates; avoid routine use.
  • Optimal injectate volumes: <0.5 mL for MBB, <1.5 mL for IA.
  • Cutoff for positive block: ≥50% pain relief.
  • Recommendations are pragmatic, balancing clinical and research needs.

ASIPP Guidelines for Facet Joint Interventions⁽¹⁾
Study Design:

• Comprehensive evidence-based guideline by the American Society of Interventional Pain Physicians (ASIPP).
• Literature review and best evidence synthesis; grading system from Level I (strong) to Level V (consensus).

Target Population:

• Patients with chronic axial spinal pain (low back, neck, thoracic), including those with failed conservative management.

Key Factors:

• Diagnosis:
  • Physical exam and clinical assessment: Level II evidence for patient selection after ≥3 months of failed conservative care.
  • Imaging: Fluoroscopic or CT guidance mandatory (Level I); SPECT, MRI, CT less reliable.
  • Diagnostic blocks (MBB): Level I–II evidence for lumbar/cervical/thoracic spine; prevalence of facet pain 27–40% (lumbar), 29–60% (cervical), 34–48% (thoracic); false-positive rates 27–47%.
• Therapeutic Interventions:
  • Lumbar RFA: Level II evidence, moderate recommendation (11 RCTs).
  • Facet nerve blocks: Level II evidence, moderate recommendation.
  • IA injections: Level IV evidence, weak recommendation (mostly ineffective without anesthetic).
• Additional Recommendations:
  • Antithrombotic therapy: May continue for moderate/low-risk procedures.
  • Sedation: Avoid opioids during diagnostic procedures; moderate sedation for therapeutic interventions.
• Trends:
  • Facet interventions increased 18.8% (2009–2018); costs rose 79%.
  • Opioid prescriptions and overdose deaths discussed in context of pain management.

ASPN Evidence-Based Clinical Guideline for Interventional Treatments of Low Back Pain⁽³⁾
Study Design:

• Multidisciplinary guideline committee (anesthesiology, neurosurgery, physiatry, radiology, pain psychology, ethics).
• Literature search (2000–present) across major databases; evidence graded using modified USPSTF criteria (RCT > prospective observational > case series > expert opinion).

Target Population:

• Adults with low back pain (LBP), including lumbar radiculopathy, myofascial pain syndrome, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, vertebral compression fractures.

Key Factors:

• Injection Therapy:
  • Epidural steroid injections: Level I evidence for disc herniation; Level II for stenosis/axial pain; Grade A, high certainty.
  • Trigger point injections: >40 RCTs; medication type does not affect outcomes; eliciting twitch response best; Grade A.
  • Facet interventions: IA injections not therapeutic; MBB prognostic for RFA; image guidance preferred; Grade A for MBB as prognostic, Grade C for IA steroid injections.
  • Sacroiliac joint injections: Diagnostic blocks gold standard; dual blocks with ≥70% pain relief most accurate; Grade A for diagnosis, Grade B for short-term relief.
• Other Interventions:
  • Intradiscal regenerative therapies (PRP, MSCs): Emerging evidence, mostly small studies.
  • Percutaneous image-guided lumbar decompression: RCTs and prospective studies support efficacy and safety.
  • Vertebral augmentation: Multiple RCTs show pain and functional improvement; Grade A.
  • Neuromodulation (SCS, PNFS): Strong evidence for post-surgical pain; moderate for non-surgical LBP.
  • Radiofrequency ablation: Multiple RCTs and observational studies support efficacy for facet-mediated pain.

ANALYSIS OF EVIDENCE
Comparison of relevant research demonstrates a broad consensus on the following points:

• Efficacy for Chronic Low Back Pain
  • Limited Therapeutic Value: All three guidelines agree that intra-articular (IA) facet joint injections have limited or no long-term therapeutic benefit for chronic low back pain (LBP). They are not recommended as a stand-alone treatment for facet-mediated pain, nor do they replace or delay the need for radiofrequency ablation (RFA). ⁽³⁾
  • Prognostic Use: IA injections may have a role as a prognostic tool before RFA, but medial branch blocks (MBB) are generally preferred for this purpose. ⁽⁶⁾
• Imaging Guidance
  • Fluoroscopy as Gold Standard: All guidelines emphasize that facet joint injections should be performed under fluoroscopic or CT guidance for accuracy and safety. Ultrasound may be considered in select cases but is not universally accepted as a replacement for fluoroscopy. ⁽⁶⁾
• Patient Selection and Diagnostic Value
  • Diagnostic Uncertainty: There is consensus that clinical history and physical examination alone are insufficient to reliably diagnose facetogenic pain. Diagnostic blocks (MBB or IA) are necessary, but even these have notable false-positive rates. ⁽⁶⁾
• Combination Therapy
  • Adjunctive Role: There is some evidence that combining IA facet injections with oral NSAIDs or other conservative therapies may be more effective than injection therapy alone, particularly in acute or inflammatory cases. ⁽³⁾

In summary, paravertebral facet joint injections, especially intra-articular, are not recommended as a stand-alone long-term therapy for chronic LBP. Their main value is as a diagnostic or prognostic tool, with MBB being preferred over IA injections. Fluoroscopic or CT guidance is essential for accuracy and safety. IA injections may have a role in acute or inflammatory cases, or as part of a multimodal approach, but should not be the only intervention. The highest quality evidence and strongest recommendations are for MBB and RFA, not for IA injections. ^(1,3,6)

References

1. Manchikanti L, Kaye AD, Soin A, et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain Physician. 2020;23(3S):S1-S127. http://www.ncbi.nlm.nih.gov/pubmed/32503359
2. Rana S, Pradhan A, Casaos J, et al. Lumbar spinal ganglion cyst: A systematic review with case illustration. J Neurol Sci. 2023;445:120539. doi:10.1016/j.jns. 2022.120539
3. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022;Volume 15:3729-3832. doi:10.2147/JPR.S386879
4. Ashmore ZM, Bies MM, Meiling JB, et al. Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis. Pain Rep. 2022;7(3):e1008. doi:10.1097/PR9.0000000000001008
5. Nisolle ML, Ghoundiwal D, Engelman E, et al. Comparison of the effectiveness of ultrasound-guided versus fluoroscopy-guided medial lumbar bundle branch block on pain related to lumbar facet joints: a multicenter randomized controlled non-inferiority study. BMC Anesthesiol. 2023;23(1):76. doi:10.1186/s12871-023-02029-9
6. 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
7. Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Pain Medicine. 2021;22(11):2443-2524. doi:10.1093/pm/pnab281
8. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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