Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Paravertebral Facet Joint Block

Paravertebral facet joint block is used to both diagnose and treat lumbar zygapophysial (facet joint) pain. Facet joint pain syndrome is a challenging diagnosis as there are no specific history, physical examination, or radiological imaging findings that point exclusively to the diagnosis. However, this diagnosis is considered if the patient describes nonspecific, achy, low back pain that is located deep in the paravertebral area. A detailed physical examination of the spine should be performed on all patients. Radiological imaging is often done as part of the workup of persistent chronic back pain to exclude other diagnoses.

Facet joint block is one method used to document/confirm suspicions of posterior elemental biomechanical pain of the spine. Often the patient presents with chronic neck, thoracic or back pain that lacks a strong radicular component, has no associated neurologic deficits, and is often aggravated by hyperextension or rotation of the spine. This policy defines chronic pain as continuous or intermittent pain that has been unresponsive to conservative measures, persisting three months or more.

Facet joint injections must be performed under fluoroscopic guidance to assure accurate placement of the needle in the facet joint or on the medial nerve branch of the facet joint. A long acting local anesthetic or corticosteroid agent is injected to temporarily denervate the facet joint. After a satisfactory block has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms.

Sacroiliac Injections

Similarly injections of the sacroiliac joint may be used to diagnose the cause of or to treat low back pain.

The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. Anatomically and biomechanically, the sacroiliac joint shares all its muscles with the hip joint and is thus subject to the unidirectional pelvic shear, repetitive and torsional forces which can contribute to SI joint pain.

Pain arising from the SI joint may mimic pain originating from the lumbar disc, lumbar facet, or hip joint. Additionally, pain coming from the SI joint is not confined to originate only from the joint; it can comprise both intra and extraarticular structures. Except in the presence of clear pathology (tumor, fracture, infection), clinical diagnosis of SI joint pain is difficult and often one of exclusion.

Indications

Paravertebral Facet Joint Blocks

The decision to treat chronic pain by invasive procedures must be based on a systematic assessment of the location, intensity, and pathophysiology of the pain. The pain must have been present for greater than 3 months. A detailed pain history is essential and must provide detail about prior treatments and responses which may include but not be limited to analgesics and physical therapy.

Paravertebral facet nerve blocks have both diagnostic and therapeutic functions.

Diagnostic blocks:

Therapeutic blocks:

Fluroscopic guidance must be used for both diagnostic and therapeutic injections to assure that the injection is properly placed.

Sacroiliac Injections

The differential diagnosis of SI joint pain requires a detailed history and thorough physical exam. Imaging with radiographs, MRI, bone scans, and CT scans do not consistently differentiate symptomatic from asymptomatic individuals.

SI joint injection can be used diagnostically or therapeutically. These are defined as follows:

• Diagnostic injections -- either an anesthetic is injected for immediate pain relief or contrast media is injected into the joint for evaluation of the integrity (or lack thereof) of the articular cartilage and morphologic features of the joint space and capsule.
  
• Therapeutic indications -- a steroid is injected into the SI joint for immediate and potentially lasting pain relief.

Fluoroscopic guidance ensures optimal access to the SI joint space in diagnostic procedures but may not be necessary for therapeutic SI injections.

When sacroiliac joint dysfunction is present in conjunction with other primary pain generators (such as lumbar radiculitis secondary to degenerative disc disease or lumbar facet arthropathy secondary to lumbar facet arthritis), treatment should first address the non-sacroiliac joint pain generators, as SI joint dysfunction may resolve once these pain generators have been successfully treated. If there is residual sacrolilac joint pain, it may be appropriate to perform SI joint injections to address the remaining pain.

Limitations

Once a diagnostic paravertebral block is negative at a specific level, no repeat interventions should be directed at that level unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate that level.

Therapeutic paravertebral nerve blocks exceeding two levels (bilaterally) on the same day will be denied as medically unnecessary.

Multiple paravertebral facet nerve blocks administered over a period of several weeks or months is not an effective method of chronic pain management and will be denied as not medically necessary. Facet joint blocks administered more frequently than four injections/spinal level/side will be denied as medically unnecessary.

Repeat therapeutic paravertebral nerve blocks at the same level, in the absence of a prior response demonstrating >50% relief of pain lasting at least six weeks, will be denied as medically necessary.

If the documentation in the medical record substantiates that the SI injections are not effective, additional injections will be considered not medically necessary.

An epidural (62311), transforaminal epidural (64483, 64484), sacroiliac joint injection (27906), or lumbar sympathetic block (64520) should not be performed on the same day as facet joint nerve block injections. Furthermore, only one type of a block or injection should be performed in a given session so that the effectiveness of its treatment can be assessed prior to attempting another type of spinal block or injection.

Any procedure performed that does not meet the “Indications and Limitations of Coverage and/or Medical Necessity” section outlined in this policy.

Any procedure performed on a beneficiary that lacks a diagnosis listed in the “ICD-9 Codes That Support Medical Necessity” section of this policy.

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
4. The drugs injected, the doses used, the site of the injection and the response should all be documented in the patient’s medical record.

Specific Documentation Requirements for Paravertebral Facet Joint Injections:

1. The patient’s medical record must indicate the medical necessity of services for each date of service billed. This must include the patient’s history (complete pain history and inclusion of failed conservative measures), physical examination and adequate follow-up documentation specific to patient response to the nerve blocks.
2. The pre-procedure evaluation leading to suspicion of the presence of the facet joint pathology must be explicitly documented in the patient’s medical record along with the post procedure conclusions. All documentation must be available to Medicare upon request.

Specific Documentation Requirements for Sacroiliac Joint Injections:

1. The medical record must provide the evaluation leading to a SI joint dysfunction diagnosis. In addition the extenuating circumstances (i.e. level of pain, interruption of activities of daily living), must be clearly documented.
2. Notation that if the SI joint pain is secondary to another primary source of pain, treatment of the primary source has been performed prior to the initiation of the SI joint injection.
3. Identification of the affected muscle(s), fascia and/or ligaments and the site of each injection noted.
4. Indication that noninvasive treatments (i.e. rest, physical therapy, NSAIDs, etc.) have been tried and were unsuccessful or contraindicated.
5. For subsequent treatments with SI joint injections, the documentation in the medical record must show the benefits received from the prior set(s) of injections.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Evidence-based practice guidelines indicate the following descriptions of the frequency of paravertebral facet blocks and SI joint injections:

Paravertebral facet joint nerve blocks in excess of more than (4) injections/ level/per year, will be reviewed on an individual consideration basis.

Patients who have gained no symptom relief of functional improvement after two injections of the SI joint should not proceed with additional injections because the likelihood of pain relief after two failed attempts is low.

If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be recorded and not a sacroiliac joint injection.

This contractor may request records when it is apparent that patients are requiring a significant number of injections to manage their pain.