Response to Comments: Facet Joint Interventions for Pain Management

Several comments were received that the requirement for the patient to have a history of pain of at least 3 months was too long and it is not realistic to require an inadequate response to a minimum of 6 weeks of conservative care. It was recommended that a two week period of NSAID use be clinically reasonable.  Exceptions for patients in whom NSAID use is contraindicated, relatively or absolutely, or not tolerated should be documented within the medical record. There was no literature submitted for review.

The LCD requires a complete evaluation to ensure medical necessity of invasive procedure(s) commensurate with recommendation(s) of national interventional pain and spine societal submitted protocols. Common indications for diagnostic facet joint nerve blocks from national society guidelines include pain of at least 3 months duration and failure to respond to conservative management. Published peer reviewed scientific literature supports that the generally accepted definition of chronic pain is pain that continues for more than 7-12 weeks despite conservative management. Traditionally, most episodes of pain will be short-lived and the majority of patients recover in about six weeks with or without treatment; hence, it is best managed conservatively, with rest, physiotherapy, and analgesics/muscle relaxants. Considering the natural course of most back pain and the value of conservative treatment, 3 months is determined to be a reasonable amount of time to wait before use of more invasive procedures. A minimum of six weeks is a reasonable amount of time to attempt non-invasive measures for relief of back pain. The conservative care treatment examples included in the LCD are not each mandated to be attempted, nor is each required for 6 weeks duration, as stated in the LCD that the non-invasive treatment examples are “as tolerated”. It is expected that documentation would include exceptions and when non-invasive measures were contradicted or not tolerated. Thank you for your comments.

A couple of comments were received recommending that the pain rating criteria be changed to 4/10 instead of 6/10. Commenters stated that 4/10 on a visual-numerical analogue pain scale (VNAS) is sufficient to constitute significant enough pain to merit treatment. Moderate pain is generally accepted to represent 4-6/10 which corresponds with pain that significantly interferes with ADLs.

Thank you for your comments. A beneficiary with a functional disability meets the criteria, even when the average pain level is less than 6/10. The LCD does not mandate both be present as stated “average pain levels of 6 or greater on a scale of 0 to 10 (primary [index] pain), or functional disability”. Therefore, if a beneficiary has a pain level of 4/10 that is interfering with ADLs, that would meet criteria of having a functional deficit. Prior to any facet joint interventions, a baseline identification of the patient’s index pain, intensity of pain (via a visual analogue scale or numeric pain rating), and any functional deficits must be documented (if they exist).

Multiple comments were received that the requirement is too restrictive for 80% pain relief with a diagnostic facet block and suggested a 50% threshold be used instead. Pain scores may not be sufficiently granular to account for a meaningful difference between an 80% vs. 50% reduction. In addition, the pain scale does not address patient functionality, and meaningful improvement in functionality can occur with even a 50% reduction in pain assessment. In many patients, but especially in our Medicare-aged patients, low back pain is often multifactorial, with several pain generators - including lumbar facet arthropathy, degenerative disc disease, stenosis, etc. Patients often have a hard time distinguishing which portion of their pain (of index pain) is being targeted.

Thank you for your comments. Published peer reviewed scientific literature has shown that the diagnosis of chronic back pain of facet origin utilizing dual controlled diagnostic blocks with the criteria of 80%  (versus 50%) pain relief and the ability to perform previously painful movements has a significantly higher prognostic validity of facet joint origin. Evidence-based national guideline indications include a positive response to controlled diagnostic blocks with a criterion standard of 75% pain relief with ability to perform prior painful movements without significant pain in order to proceed to therapeutic facet joint interventions. Consideration of the evidence supports that utilizing appropriate diagnostic criteria substantially decreases inappropriate and unnecessary treatment.

It is acknowledged that the quantitation of benefit is difficult. Medicare recognizes the multiplicity of potential pain generators in these patients, some of which may be accounting for a more significant aspect of the disability. After consideration, the diagnostic requirement will be revised to account for functional improvement as a separate stand-alone criteria from pain relief. Therefore, either a minimum of 80% pain relief or at least 50% improvement in the ability to perform previously painful movements will be required from each diagnostic medial branch block (MBB). It is the expectation of Novitas and CMS that providers document in a meaningful method that can be followed in later evaluations to assess benefit. Careful documentation and appropriate coding will not impair the beneficiary's treatment. It remains the responsibility of the provider to show "significant" benefit to a procedure or treatment, if asked by the MAC for evidence.      

A few comments were received that the requirement for diagnostic dual medial branch blocks (as opposed to single) seems to be generally accepted, but it does extend the number of procedures (as well as patient inconvenience) in eventually reaching what may be a clear and appropriate conclusion.

Published peer reviewed scientific literature has shown a significant percentage of false-positive rates utilizing a single diagnostic block. Consideration of the evidence (literature and national society guidelines) supports the prognostic validity of utilizing the double-injection technique as opposed to a single diagnostic medial nerve block substantially decreases inappropriate and unnecessary treatment. In light of the above, if a patient receives unquestionable pain relief from a single block, but it recurs and responds with the same amount of benefit as it did initially, the best expectation of benefit from a likely irreversible procedure can be substantiated. No change will be made to the dual diagnostic requirement. Thank you for your comments.

A comment was received that the utility of clinical history and examination findings for diagnosis of facet pain prior to consideration of any facet intervention has been shown to only be valid for constellations of multiple signs and/or symptoms. No individual clinical maneuver has been shown to be diagnostically useful with a p less than 0.05. As well, clinical findings are more frequently absent in patients greater than 65 years of age. Accordingly, there is no medical basis for a LCD to establish any requirement for any certain single specific positive clinical finding or maneuver.

Thank you for your comment. A complete evaluation is one element that is required to ensure medical necessity of invasive procedures commensurate with recommendation of national interventional pain and spine societal submitted protocols. Clinical signs alone cannot diagnose facet joint-mediated pain, but is one of the requirements in selecting candidates for controlled diagnostic local anesthetic blocks.

A few comments were received regarding the patient that presents with multi-factorial pain with symptoms of both radiculopathy due to anatomic stenosis and facet pain. It was recommended that the final LCD support identification and resolution of any radicular pain component prior to evaluation of the facet pain component.

It is outside of the scope of the LCD to mandate how providers prioritize and treat multi-factorial pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first procedure(s) fail to produce the desired effect or to rule out the diagnosis, then it would be expected that the provider would proceed to the next logical test or treatment indicated. It is expected that documentation would include a complete evaluation as well as any prior treatments for any radicular pain components (if applicable) as well as examination findings/signs of suspected facet joint source of pain. Thank you for your comments.

One comment was received that did not support repeat local anesthetic medial branch blocks as a therapeutic modality. The commenter stated that literature supporting efficacy is poor and widely criticized. There was no literature submitted for review.

The evidence for therapeutic facet joint nerve block injections is limited. Review of available evidence is fair to good; however, review of the available evidence for radiofrequency neurotomy is also poor/fair to good (fair for cervical, poor for thoracic, and good for lumbosacral region). The general consensus among national society guideline recommendations for therapeutic interventions is for either modality (facet joint nerve blocks or radiofrequency ablation). Novitas takes into consideration the safety and efficacy of the techniques and procedures as well as the clinical utility, but the LCD is not intended to direct care. Novitas expects the provider to determine the appropriate therapeutic intervention within the acceptable standards of care. Thank you for your comment.

One comment was received that did not support repeat intraarticular facet injection for therapeutic purposes where the duration of pain improvement with a technically adequate initial facet injection is less than 3 months. 

The available evidence for therapeutic intraarticular injections is limited to poor. It is expected that the use of therapeutic intraarticular facet block(s) would be limited to select situations only when medial branch blocks cannot be performed due to specific documented anatomic restrictions. The LCD requires at least 50% pain relief for at least three (3) months from the prior therapeutic injection for subsequent therapeutic injections at the same anatomic site. Thank you for your comment.

A couple of comments were received opposed to the wording of the following statement in the “Covered Indications” section of the draft LCD: “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”.

One commenter stated that if there is no other explanation for the pain, then there would be no need for a diagnostic block as you would already have a diagnosis. Another commenter thought this was an unreasonable restriction as patients have multilevel degenerative changes throughout their spine contributing to the constellation of pain. If the provider attributes any symptom to any pathology, even if minor, the patient would not be eligible for the procedure under the proposed LCD.

Thank you for your comments. The key words in the statement are “non-facet pathology”. Diagnosing pain of facet joint origin is usually one of exclusion and the intent of the statement is that it would not be medically reasonable and necessary to select a candidate for a diagnostic facet joint block if there were other plausible explanations for the pain. Understanding that pain could be multi-factorial, it would be expected that the provider would treat the known diagnosis first before proceeding to additional diagnostic tests or treatment as indicated. Having multi-factorial pain would not restrict a patient from services. Documentation is expected to include a complete evaluation as well as any prior treatments (if applicable) as well as examination findings/signs of suspected facet joint source of pain.

One comment was received in support the performance of this procedure under fluoroscopy, or only where failure of fluoroscopy has been demonstrated, under CT guidance. The commenter stated that routine performance under CT is not cost effective and usually involves greater costs and greater radiation dose exposure to the patient. There is limited evidence that ultrasound guidance may be useful, but this is nascent technology and performance of facet interventions under ultrasound guidance is not recommended at the present time. No literature submitted for review.

Thank you for your comment. Per code descriptor(s), the facet joint interventions addressed in this policy must be performed under fluoroscopy or CT guidance. There was no literature submitted showing better outcomes from fluoroscopy versus CT guided facet joint interventions. No change will be made to the final policy mandating the use of one imaging over the other. Utilizing ultrasound guidance or no guidance for these procedures is non-covered.

A comment was received requesting coverage of cooled radiofrequency (RF) technology for facet joint denervation. Aside from its’ name (which can be a bit confusing), cooled RF is similar to standard RF. Like standard RF, cooled RF uses a continuous (non-pulsed) radiofrequency electrical current to generate a thermal lesion at temperatures greater than or equal to 80 degrees Celsius. Cooled RF is not pulsed radiofrequency nor is it cryoablation. Other MACs, four (4) medical societies and ECRI Institute have validated that the ablative temperature for cooled RF reaches and/or exceeds 80 degrees Celsius in tissues adjacent to the probe tip similar to ablative temperatures with standard RF procedures. 

Clarification appreciated. Tip temperature is a requirement for ablative instrument. Concern is expressed from the literature accounts of potential burn to adjacent tissue risk due to larger tissue volume heated with this technology. However, if criteria are met for ablative technique and temperature required for code description, technology may be appropriate for inclusion.

One commenter requested to allow all techniques and devices generating tissue temperatures above 45 degrees Celsius to be used. While lesions produced at 80 degrees Celsius or above are customary, somewhat lower temperatures, especially with longer lesioning times may be less painful post-operatively and therefore desirable. It was recommended that the LCD simply exclude all modalities that do not achieve temperatures in excess of 45 degrees Celsius and specifically exclude pulsed RF. Use of a laser or focused ultrasound for the treatment of facet pain should be considered investigational techniques at this time. There is no proven role for “cold” laser technology in addressing facet pain.

Non-thermal modalities for facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are not covered. Thank you for your comment.

Several comments were received regarding the conscious sedation limitation in the proposed draft LCD. In general, commenters were in agreement that conscious sedation should not be used for most interventional procedures, especially diagnostic medial branch blocks, where sedation could affect a patient’s perceived relief for the duration of anesthetic. However, for cervical and lumbar radiofrequency ablations, patients benefit from mild conscious sedation. These procedures, when performed correctly, can take a long time and often include wide-gauge needles that are much more painful than the narrow-gauge needles used for medial branch blocks. It was recommended that minimal to moderate conscious sedation be allowed for facet ablations.

Mild sedation is optional for procedures in this policy and is expected to include documentation of medical necessity.  Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks. This restriction does not apply to radiofrequency ablations. The final policy will be revised accordingly. Thank you for the comments.

One comment was received in agreement that facet interventions can be provided equivalently in a hospital, ambulatory surgical center or office setting under fluoroscopic guidance with the immediate availability of resuscitative equipment and supplies as outlined in the draft LCD.

Thank you for your comment and support of the LCD.

One commenter stated that the provider qualifications are unclear. Specifically, in this statement “If a procedure requires facility credentialing or privilege approval when performed in an inpatient or outpatient hospital setting, the provider must possess those credentials in order to receive reimbursement for that procedure whether performed in a hospital facility or elsewhere.” The word "elsewhere" needs to be more specific, or least say office site or service or ASC.

Provider qualifications suggest that the provider of these services to the Medicare beneficiary be both adequately trained and credentialed by national and local evaluation of training experience sufficient to allow for permission to perform these procedures safely and with efficacy such that no facility or individual becomes liable for inappropriate care and management on the basis of failure to meet national and local standards of care. "Elsewhere" is defined in the policy as "Only those settings with immediate availability of equivalent support services and personnel as those in a hospital will be considered appropriate places of service for purpose of Medicare reimbursement." This statement is in the policy directly following the statement with “elsewhere”. There will not be specific sites included in the policy. Thank you for your comment.

One comment was received requesting that the following provider qualification “grandfathering clause” be deleted: “Demonstration of satisfactory performance of the specific interventional pain management services in this policy on a regular basis over the five years immediately preceding implementation of this policy. Medicare considers an average of ten services per month to meet this requirement, and may be substantiated by Medicare or other payer claim history supported by patient medical records of appropriate care, procedural performance and outcomes.”

The provider qualification statement in question is not stand-alone criteria. In addition to acceptable training or certification, the LCD outlines the following two requirements that must both be met: 

• "All aspects of the procedure and its related care are within the scope of practice of the provider’s professional licensure; and
• All procedures are performed by appropriately trained providers in the appropriate setting.“   

The statements under “Acceptable training or certification” requirements included in the “Provider Qualification” section will not be removed in the final policy. Thank you for your comment.

One comment was received requesting that there be more clarity about non physician credentialing. Most have no radiation safety training or image based interventional training whatsoever. 

Novitas requires documented radiation safety credentialing (equivalent to that of MD, DO, DPM as required for program completion and national certification) for individuals utilizing radiation as an integral part of a reimbursed procedure.  This is required for all procedures involving imaging and contrast, including ultrasound, in addition to those in this policy. 

A couple of comments were received regarding the provider qualifications specifically mentioning Interventional Pain Management and Anesthesiology. If specialties are going to be specifically mentioned, the commenters recommended that as fellowship trained physiatrists, Physical Medicine and Rehabilitation be included. 

Thank you for your comments. The provider specialties listed in the LCD are examples only (as stated with "e.g."). The examples mentioned in the LCD are not intended to be all inclusive. Novitas recognizes that Physical Medicine and Rehabilitation is one of the top performing specialties, and the intent was not to exclude any one particular specialty. The list will not be revised as it is included for example purposes only and has no bearing on coverage. The emphasis is on training and experience of the provider which may come from various recognized training programs. Documentation of such is required for Medicare reimbursement for the treatment of beneficiaries to ensure safety and efficacy.

One comment was received regarding the provider qualifications that strongly recommended that this LCD restrict performance of all facet interventions to licensed physicians and surgeons with specialty designation in the fields of interventional pain, interventional radiology, anesthesiology, physical and rehabilitation medicine, neurosurgery, and orthopedic surgery and absolutely exclude mid-level providers including CRNA’s, nurse practitioners and physician assistants.  The performance of all facet interventions requires a high degree of skill, both in diagnosis and technical facility with use of fluoroscopic imaging and needle manipulative skills.  While RF lesioning has a very good record of safety, this is in large measure due to extensive training during residency and fellowship and sometime post-graduate CME training as well as professional judgement. The learning curve for procedural competence is well over 100 procedures in the simplest region, the lumbar spine. The level of skill required for cervical and thoracic procedures is greater with less than a third of interventional pain physicians regularly performing cervical or thoracic RF lesioning following 4 years of medical school, 4 years of residency and 1 year of fellowship. 

Thank you for your comment. Novitas requires documented competency and safety credentialing (equivalent to that of MD, DO, DPM as required for program completion and national certification).  The emphasis is on training and experience of the provider which may come from various recognized training programs. Documentation of such is required for Medicare reimbursement for the treatment of beneficiaries to ensure safety and efficacy.

A few commenters requested inclusion of Nurse Anesthesia training programs for Chronic Pain Management and National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) voluntary nonsurgical pain management (NSPM) subspecialty certification as evidence for sufficient training to allow reimbursement for independent practice for the procedures listed in this LCD. Additionally, the commenters requested alterations in provider qualifications to suggest provider neutrality. The use of the language “accepted standards of medical practice” fails to recognize qualified non-physician healthcare professionals.

Thank you for your comments. The language “furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of  malformed body member” is taken directly from the CMS Internet-Only Manual Publication 100-08, Chapter 13, Section 13.5.1 Reasonable and Necessary Provisions in LCDs. It is the expressed purpose of this LCD to allow for medically necessary treatment of the Medicare beneficiary provided by appropriate personnel in the appropriate place of service, as dictated by the safety and individualized needs of the beneficiary. Assurance that the provider is adequately trained and experienced to supply appropriate therapy as well as manage the outcome of both the therapy and disease is the fundamental premise of the Medicare Program. When documentation by NBCRNA (or equal national certifying authority) includes documentation of training, experience and evaluation of techniques, evaluation and indications with documentation of disease, alternative treatments, outcomes and complications, commensurate with national standards for Interventional Pain Management, Novitas will review.

One commenter requested clarification of several statements from the American Society of Interventional Pain Physicians (ASIPP) Interventional Pain Management (IPM) Guidelines. Specifically, the following:

• "Somatic or nonradicular neck, mid back, upper back or low back and headache, upper extremity pain, chest wall pain or lower extremity pain of at least 3 months duration.
• Lack of disc herniation or evidence of radiculitis.
• Lack of evidence, either for discogenic or sacroiliac joint pain.”

The commenter stated that as written the statements were not clear.

These excerpts are from the ASIPP “common indications for diagnostic facet joint nerve blocks” that are listed in the “Summary of Evidence” section of the LCD. This is a new section in the LCD used to summarize pertinent literature and/or guidelines that were reviewed and used to determine covered indications and limitations for this LCD. This language is taken directly from the ASIPP guidelines and was not written by Novitas; therefore, will not be revised.  Clarification will be made in the “Summary of Evidence” section that those indications are from the ASIPP guidelines.

The LCD has a “Covered Indications” section which requires that for facet interventions to be considered medically reasonable and necessary that there be a “history of pain that is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication”

As stated earlier, radiculopathy that is present along with suspected facet mediated pain (due to multi-factorial etiology) would not preclude someone from getting facet joint interventions. It would be expected that the provider would treat the pain systematically with the known diagnosis first before proceeding to additional diagnostic tests or treatment as indicated. It is expected that documentation would include a complete evaluation as well as any prior treatments for any radicular pain components (if applicable) as well as examination findings/signs of suspected facet joint source of pain. Thank you for your comment.

One comment was received stating that there is no evidence or recommendations for routine use of non-ionic imaging contrast for facet procedures. Exposing every patient to iodine contrast has little benefit and exposes and sensitizes patients to iodine unnecessarily. The commenter is unaware of any guideline stating the need for routine contrast use. This is an unnecessary risk and expense.    

The requirement for contrast is recommended by national associations and proponents of these procedures in all submitted and reviewed protocols. There was no literature submitted for review showing a lack of benefit or diminished outcome from using contrast.  After finalization, the LCD reconsideration process may be utilized for consideration of requests with submission of supporting published peer reviewed scientific literature. Thank you for your comment.                 

Several comments were received requesting an additional number of sessions. A couple of commenters were in general agreement with the LCD’s proposed restrictions of the number of procedures to be performed per region per year, but requested that if the final LCD requires dual diagnostic blocks, that this be increased to 6 sessions, instead of 5, because the limit of 5 would not allow sufficient medial branch blocks to be performed to pursue subsequent therapeutic RF lesioning. A couple of commenters requested that 4 RF sessions per region be allowed instead of 2, or, that there be some other accommodation to allow 2 sets of left and right ablations in the same region in a 12-month period. 

Thank you for your comments. Frequency limitations have been placed to comply with national standards. Novitas has taken into consideration the recommended frequency of interventions established by national society guidelines, utilization data, and evidence from medical literature which is not well-established for the clinical efficacy and utility of therapeutic facet joint injections. Five (5) facet joint intervention sessions per region per rolling 12 months has been determined to be a reasonable amount when provided in accordance with the recommendations. The total number of thermal RF ablation sessions will remain at 2 per region per rolling 12 months. There was no literature submitted showing that undergoing separate sessions for facet ablation (right then left side or vice versa) improves long-term health outcomes over performing a bilateral facet ablation procedure in one session. National association practice guidelines recommend that for therapeutic medial branch neurotomy, all regions be treated at the same time, provided all procedures are performed safely. Additional sessions or segmentation of sessions will be evaluated upon redetermination (appeal), if necessary. 

One comment was received requesting that the performance of one additional nerve level of diagnostic medical branch block and the RF lesioning following an incomplete RF result be considered to be completion of the prior RF procedure and thus, not count against the allowed total procedures per region per year.

As stated in the response to Comment # 23, the total number of facet joint intervention sessions is 5 per region per rolling 12 months. The total number of thermal RF ablation sessions is 2 per region per rolling 12 months. Facet joint injections (diagnostic or therapeutic) are limited to three (3) levels (unilateral or bilateral) per anatomic region per session. Thermal RF ablation sessions are limited to no more than five (5) levels (unilateral or bilateral) per anatomic region per session. Any extenuating circumstances requiring additional sessions or segmentation of sessions will be evaluated upon redetermination (appeal), if necessary. Thank you for your comment.

A few comments were received requesting additional ICD-10 diagnosis codes be added to the policy as covered. One request was for diagnosis code M54.5 Low Back Pain because facet joint disease can manifest clinically as low back pain. Another request stated that the LCD should continue to allow use of descriptive ICD codes including dorsopathy, cervicalgia, lumbago and other codes identifying painful dorsal spine conditions to support medical necessity.  Where percutaneous facet cyst lysis is performed, ICD codes reflective of “bursal cyst, other site” M71.38 and, if clinically appropriate, the use of ICD codes reporting radiculopathy with or without Herniated Nucleus Pulposus (HNP) should be allowable. Another commenter noted that inflammatory, trauma, demyelination, post-surgical, sacral and spinal stenosis have been extracted from existing policy and should be reconsidered. The commenter agrees with the Novitas’ position to move away from “not otherwise specified” (NOS) indications and hopes upon reconsideration less common but important indications would be reconsidered or at least be reconsidered on appeal with appropriate guidance.

Thank you for your comments. Low back pain can describe multiple signs of pelvic and lower abdominal conditions unrelated to the spine, for which facet block would not be considered appropriate. It is Novitas’ expectation that these procedures would not be considered unless a paraspinal process is first identified and defined. Therefore, lumbago and cervicalgia will not be added. After review, Novitas agrees to add the requested ICD-10 code M71.38 “Other bursal cyst, other site” as another option for facet cyst lysis and also agrees to add coverage for inflammatory spondylopathies (M46.82-M46.87). After finalization, the LCD reconsideration process may be utilized for consideration of requests with submission of supporting published peer reviewed scientific literature.

One commenter recommended removal of “syndrome” from any LCD text. “Syndrome” is pejorative in regard to facet pain as this implies only a collection of signs and symptoms. Facet pain is an anatomic pain process with a well-defined pathophysiology, etiology, anatomy, neurology and enjoys standardized diagnostic and therapeutic modalities. 

“Facet joint syndrome” is a term that is widely accepted and used in peer reviewed literature as well as national society guidelines. Therefore, inclusion of the term is for informational purposes in the general information section of the LCD and has no bearing on coverage. Thank you for your comment.

One commenter recommended that that the text of the proposed LCD omit references to an inflammatory etiology as there is no evidence that the medial branch is inflamed or is the subject of neuropraxic injury and it is understood that facet pain can be caused by several non-inflammatory mechanical processes including facet fracture.

Thank you for your comment. The reference to “inflammation of the medial branch nerve” will be revised in the final LCD. This will not change coverage.

One commenter stated that there is no evidence supporting the performance of any diagnostic local anesthetic neural blockade using steroid combined with local anesthetic. There may be prolongation of pain relief by up to 50% when dexamethasone is combined with local anesthetic, but this has only been studied for major plexus block and not specifically for neural blockade of the medial branch. The commenter requested local anesthetic-only neural blockade techniques. 

Both diagnostic and therapeutic medial branch blocks may be acceptably performed with or without steroids. It is outside of the scope of the LCD to mandate local anesthetic agent neural blockade techniques only. Thank you for your comment.

One commenter asked “If not included in this policy, then what will become of sacral RF lesioning?”

This policy does not address sacral procedures including injections or neurotomies. Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.