Description
Facet joint are joints in the spine that aid stability and allow the spine to bend and twist. Facet joint injections are a type of interventional pain management technique used to diagnose or treat back pain. Intraarticular blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. The review will identify whether the treatment meets indications for coverage and whether it exceeds the limitations of coverage.
Affected Code(s)
64490, 64491, 64492, 64493, 64494, 64495
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 4 – Part B Hospital, §20.4 – Reporting of Service Units
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38801: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 02/03/2022
10. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 02/03/2022
11. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58403 - Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 11/06/2022
12. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58405 - Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 11/06/2022
13. CGS Administrators, LLC, Local Coverage Determination (LCD) L38773 – Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 03/17/22
14. CGS Administrators, LLC, Local Coverage Article (LCA) A58364 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 11/16/2023
15. First Coast Service Options (FCSO), Inc. Local Coverage Determination (LCD) L33930 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 04/25/21
16. First Coast Service Options (FCSO), Inc. Local Coverage Article (LCA) A57787 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 10/03/18, Revised 11/30/2023
17. National Government Services (NGS), Inc. Local Coverage Determination (LCD) L35936 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 02/10/22
18. National Government Services (NGS), Inc. Local Coverage Article (LCS) A57826 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 12/05/19; Revised 11/06/2022
19. Novitas Solutions, Inc. Local Coverage Determination (LCD) L34892 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 04/25/21
20. Novitas Solutions, Inc. Local Coverage Article (LCA) A56670 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 07/11/19; Revised 11/30/2023
21. Palmetto GBA Local Coverage Determination (LCD) L38765 – Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 05/18/2023
22. Palmetto GBA Local Coverage Article (LCA) A58350 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 04/13/2023
23. WPS Insurance Corporation Local Coverage Determination (LCD) L38841 - Facet Joint Interventions for Pain Management; Effective 04/25/21, Revised 03/30/2023
24. WPS Insurance Corporation Local Coverage Article (LCA) A58477–– Billing and Coding: Facet Joint Injections for Pain Management; Effective 04/25/21; Revised 03/30/2023
25. AMA CPT Codebook, 50 - Bilateral Procedures, 59 - Distinct Procedural Service, Appendix D Summary of CPT Add-on Code