Description/Background
Facet joints (also called zygapophysial joints or z-joints), posterior to the vertebral bodies in the spinal column and connecting the vertebral bodies to each other, are located at the junction of the inferior articular process of a more cephalad vertebra and the superior articular process of a more caudal vertebra. These joints provide stability and enable movement, allowing the spine to bend, twist and extend in different directions. They also restrict hyperextension and hyperflexion.

Facet joints are clinically important spinal pain generators in patients with chronic spinal pain. In patients with chronic low back pain, facet joints have been implicated as a cause of the pain in 15% to 45% of patients. Facet joints are considered as the cause of chronic spinal pain in 48% of patients with thoracic pain and 54% to 67% of patients with chronic neck pain. 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 findings are of little value in determining the source and location of "facet joint syndrome," a term originally used by Ghormley and referring to back pain caused by pathology at the facet joints. Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting patients for controlled local anesthetic blocks of either the medial branches or the facet joint itself.

Medical necessity management for paravertebral facet injections includes an initial evaluation including history and physical examination and a psychosocial and functional assessment. The following must be determined: nature of the suspected organic problem; non-responsiveness to conservative treatment*; level of pain and functional disability; conditions that may be contraindications to paravertebral facet injections; and responsiveness to prior interventions.

The most common source of chronic pain is the spine, and about two-thirds of the U.S. population suffers from spinal pain sometime during their lifespan. Facet joint interventions are used in the treatment of pain in certain patients with a confirmed diagnosis of facet joint pain. 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 patients must understand the procedure and its potential risks and results. Facet joint injections or medial branch nerve blocks require guidance imaging.

Policy 
Indications for Facet Joint Injections or Medial Branch Nerve Blocks:

To confirm disabling non-radicular low back (lumbosacral),mid back (thoracic) or neck (cervical) pain*, suggestive of facet joint origin as documented in the medical record based upon ALL of the following: 

• History, consisting of mainly axial or non-radicular pain unless stenosis is caused by synovial cyst (Khan, 2006; Manchikanti, 2013, 2009); AND
• Lack of evidence, either for discogenic or sacroiliac joint pain as the main pain generators (Manchikanti, 2013, 2009); AND
• Lack of disc herniation or evidence of radiculitis as the main pain generators unless stenosis is caused by synovial cyst (Khan, 2006; Manchikanti, 2013, 2009); AND
• Facet blocks should not be performed at same levels as previous surgical fusion; AND
• Pain causing functional disability or average pain levels of ≥ 6 on a scale of 0 to 10 (Manchikanti, 2013, 2009; Summers, 2013); AND
• Duration of pain of at least 3 months (Manchikanti, 2013, 2009); AND
• Failure to respond to conservative non-operative therapy management* for a minimum of 6 weeks in the last 6 months prior to facet injections, or details of active engagement in other forms of active conservative non-operative treatment, if the patient had prior spinal injections, unless the medical reason this treatment cannot be done is clearly documented (Manchikanti, 2013; Summers, 2014); AND
• All procedures must be performed using fluoroscopic or CT guidance (Amrhein, 2016; Weininger, 2013).

NOTE: Ultrasound guidance is not a covered benefit and procedure performed using ultrasound guidance are not reimbursable.

Policy Guidelines  

• There must be a minimum of 14 days between injections or 7 days if the most recent injection was diagnostic facet nerve blocks with local anesthetic only (Manchikanti, 2013).
• The patient continues to have ongoing pain or documented functional disability (pain causing functional disability or pain level ≥ 6 on a scale of 0 to 10) (Manchikanti, 2013, 2009; Summers, 2013). There must be a positive response of ≥ 50% pain relief or improved ability to function or a change in technique, for example from an initial intraarticular facet block to a medial branch nerve block to be considered. Repeat therapeutic injections should be performed at a frequency of 2 months or longer provided that at least 50% relief is obtained for a minimum of 2 months after the previous injection (Manchikanti, 2013).
• Conservative therapy
  • For a diagnostic injection more than one month from the prior diagnostic injection, the patient is actively engaged in other forms of active conservative non-operative treatment, unless pain or another medical reason prevents the patient from participating in conservative therapy*
  • For therapeutic injections, the patient is actively engaged in other forms of active conservative non-operative treatment, unless pain or another medical reason prevents the patient from participating in conservative therapy* (Qassem, 2017; Summers, 2013).
• In the diagnostic phase a maximum of 2 procedures may be performed. In the therapeutic phase a maximum of 4 procedures per region every 12 months except under unusual circumstances such as a recurrent injury. (NOTE: Unilateral facet blocks performed at the same level on the right vs. left within 2 weeks of each other would be considered as one procedure) (Manchikanti, 2013).
• If the procedures are applied for different regions, they may be performed at one week intervals for most types of procedures (Manchikanti, 2013).
• Radiofrequency neurolysis procedures should be considered in patients with at least 70% pain relief or improved ability to function, from medial branch nerve blocks, but with insufficient sustained relief (less than 2-3 months improvement) (Manchikanti, 2013; Summers, 2013).

CONTRAINDICATIONS FOR FACET JOINT INJECTIONS:

• History of allergy to contrast administration, local anesthetics, steroids, or other drugs potentially utilized;
• Hypovolemia;
• Infection over puncture site;
• Bleeding disorders or coagulopathy;
• History of allergy to medications to be administered;
• Inability to obtain percutaneous access to the target facet joint;
• Progressive neurological disorder which may be masked by the procedure;
• Pregnancy;
• Spinal infection; OR
• Acute fracture

Rationale
Facet injections, in the cervical, thoracic and lumbar regions of the spine, are divided into two phases: the diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given, and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. If there is no pain relief after the diagnostic injection (negative block), the therapy is not continued. There are no historical, physical or imaging studies that are diagnostic of facet joint pain. The diagnosis is one of exclusion that is facilitated by performing a diagnostic block of the facet joint or nerves (medial branch of the posterior primary ramus) innervating the joints.

Acute pain caused by injury, surgery or illness generally lasts for a short period of time, and usually disappears when the underlying cause has been treated or has healed. Chronic pain persists even when the initial cause (injury, disease) has resolved. The intensity will vary from mild to severe disabling pain that may significantly reduce quality of life.

Facet injections (intraarticular injections and medial branch blocks) are used to treat chronic back pain from facet joint origin, using anesthetic agents with or without or steroids. A facet block is an injection into or around the synovial joints formed by the facets on the articular processes of contiguous vertebrae.

The American Society of Anesthesiologists (ASA) (1997) has stated that the goals of pain management are to:

• Optimize pain control, recognizing that a pain-free state may not be achievable.
• Minimize adverse outcomes and costs.
• Enhance functional abilities and physical and psychological well-being.
• Enhance the quality of life for individuals with chronic pain.

In 2009, Manchikanti and colleagues issued updated comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. The guideline recommends diagnostic facet joint nerve block for individuals with pain that has lasted at least 3 months with failure to respond to conservative therapy, including chiropractic care, physical therapy modalities with exercises and non-steroidal anti-inflammatory agents.

In a 2008 update of the Cochrane Database Systematic Review, Staal and associates stated that the effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent and dosage generally found in randomized controlled trials (RCTs) points to the need for clinically valid comparisons in a literature synthesis. However, it cannot be ruled out that specific subgroups of individuals may respond to a specific type of injection therapy.

A technology assessment published by the Agency for Healthcare Research and Quality (AHRQ, 2015) conducted a systematic review of injection therapies for lower back pain that included 13 trials for facet joint injections. The publication concluded:

Studies found no clear differences between various facet joint corticosteroid injections (intra-articular, extra-articular [peri-capsular] or medial branch) and placebo interventions. There was insufficient evidence from one very small trial to determine effects of peri-articular sacroiliac joint corticosteroid injections.

Chou and colleagues (2009) evaluated clinical data for the American Pain Society Clinical Practice Guideline: Nonsurgical Interventional Therapies for Low Back Pain. They found that evidence from randomized, placebo-controlled trials showing benefits of most interventional injection therapies for back pain is limited. More evidence is needed to demonstrate efficacy of injection therapies that target presumed facet joint for sacroiliac joint pain. For radiculopathy, there is fair evidence of benefits associated with epidural steroid injections; however, the decision to use epidural steroid injection should take into account the short-term nature of symptom relief and inconsistent results of epidural steroid trials. More well-designed randomized trials are needed to guide appropriate use of injection therapy for back pain.

Pain management presents a major challenge to health care providers because of its complex natural history and unclear etiology. Clinical decision making for diagnosing and treating chronic pain is difficult due to the subjective nature of pain. Although there are clinical studies for facet injections, the results vary with respect to the degree and duration of pain relief, and it is difficult to standardize treatment models.

In a retrospective multicenter study of 262 participants, Cohen and colleagues (2008) compared lumbar zygapophyseal joint radiofrequency denervation success rates between the conventional 50% or more thresholds and the more stringently proposed at least 80% cutoff. A total of 145 participants had greater than 50% but less than 80% relief after medial branch block and 117 obtained 80% relief. The authors concluded that using more stringent pain relief criteria when selecting candidates is unlikely to improve success rates, and may lead to misdiagnosis and withholding a potentially valuable treatment.

Diagnostic medial branch blocks have been established as the standard for diagnosing facetogenic pain. In a prospective multicenter study, Cohen and colleagues (2013) evaluated optimal cutoff threshold for diagnostic lumbar facet blocks. A positive diagnostic block was defined as pain relief of 50% or more during the injection procedure with the individual being able to carry out previously painful maneuvers. The authors concluded that employing more stringent selection criteria would likely result in withholding treatment from a substantial number of individuals, without improving success rate.

References

1. Atluri, S., Datta, S., Falco, F.J.E., (2008). Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician, 11(5), 611-629. ISSN 1533-3159
2. Binder, D.S. & Nampiaparampil, D.E. (2009). The provocative lumbar facet joint. Curr Rev Musculoskelet Med, 2(1), 15-24. doi: 10.1007/s12178-008-9039-y.
3. Bogduk, N. (2005). A narrative review of intraarticular corticosteroid injections for low back pain. Pain Med , 6(4), 287-296. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16083458
4. Datta, S., Lee, M., Falco, F.J.E., Bryce, D.A. & Hayek, S.M. (2009). Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician, 12(2), 437-460. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0027734
5. Falco, F.J.E., Erhart, S., Wargo, B.W., Atluri, S., Datta, S. & Hayek, S.M. (2009). Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician, 12(2), 323-344.
6. Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R.M., Boswell, M.V., Buenaventura, R.M., Bryce, D.A., . . . Hirsch, J.A.(2013). An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: Part II: Guidance and recommendations. Pain Physician, 16(2 suppl), S49-S283. ISSN 1533-3159.
7. Manchikanti, L., Boswell, M.V., Singh, V., Benyamin, R.M., Fellows, B., Abdi, S. Buenaventura, R.M., . . . ASIPP-IPM. (2009). Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician, 12(4), 699-802. ISSN 1533-3159.
8. Manchikanti, L., Singh, V., Falco, F.J.E., Cash, K.A. & Pampati, V. (2010). Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: A randomized, double-blind, controlled trial with a 2-year follow-up. International Journal Medical Science, 7(3), 124-135. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880841
9. Manchikanti, L., Boswell, M.V., Singh, V., Pampati, V., Damron, K.S. & Beyer. C.D. (2004). Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders, 5, 15. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC441387
10. Manchikanti, L., Pampati, V., Singh, V., Boswell, M.V., Smith, H.S. & Hirsch, J.A. (2010). Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data. BMC Health Serv Research, 10, 84. doi: 10.1186/1472-6963-10-84
11. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain.  Spine. 2009; 34(10):1078-1093.
12. Chou R, Loeser J, Owens D, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain. Spine. 2009; 34(10):1066-1077.
13. Cohen SP, Stojanovic MP, Crooks M, et al. Lumbar zygapophysical (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J. 2008; 8:498-504.
14. Cohen SP, Strassels SA, Kurihara C, et al. Establishing a optimal "cutoff" threshold for diagnostic lumbar facet blocks: A prospective correlational study. Clin J Pain. 2013; 29:382-391.
15. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009; 12(4):699-802.
16. Manchikanti L, Singh V, Falco FJ, et al. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. 2010a; 13(6):535-548
17. Manchikanti L, Singh V, Falco FJ, et al. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. 2010b; 13(5):437-450.
18. Manchikanti L, Singh V, Falco FJ, et al. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010c; 7(3):124-135.
19. Agency for Healthcare Research and Quality (AHRQ). Pain Management Injection Therapies for Low Back Pain. 2015 March. Technology Assessment Report ESIB081. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf. Accessed on June 22, 2015.
20. American Pain Society (APS) and American Academy of Pain Medicine (ASPM). Clinical guideline for the evaluation and management of low back pain: Evidence review. 2009. Available at: http://americanpainsociety.org/uploads/education/guidelines/evaluation-management-lowback-pain.pdf. Accessed on May 27, 2015.
21. American Pain Society. Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009; 34(10):1066-1077.
22. American Society of Anesthesiologists (ASA). Task Force on Pain Management: General practice guidelines for chronic pain management. Anesthesiology 1997; 86(4):995-1004
23. National Government Services. Jurisdiction J-K. Local Coverage Determination for Pain Management (L28529). Revision 12/16/2014. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on May 27, 2015.
24. National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. 2009. Available at: http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf. Accessed on May 27, 2015
25. North American Spine Society (NASS). Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. NASS. 2012. Available at:  https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf. Accessed on June 23, 2015
26. North American Spine Society (NASS). Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. NASS. 2012. Available at:  https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf. Accessed on June 23, 2015
27. Staal JB, de Bie R, de Vet HC, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008; (3):CD001824.
28. American Academy of Orthopaedic Surgeons. Spinal injections. December 2013. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00560. Accessed on May 27, 2015
29. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Back pain. September 2013. Available at: http://www.niams.nih.gov/Health_Info/Back_Pain/default.asp. Accessed on May 27, 2015.

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. 

Definitions 
*Conservative Therapy: (spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (epidural, facet, bursal and/or joint, not including trigger point) and diathermy can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program** and/or chiropractic care.

**Home Exercise Program (HEP): the following two elements are required to meet guidelines for completion of conservative therapy:

• Information provided on exercise prescription/plan AND
• Follow-up with member with documentation provided regarding completion of HEP, (after suitable 4-6 week period) or inability to complete HEP due to physical reason, i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute "inability to complete" HEP).

Terminology: Facet Injections; Facet Joint Blocks; Paravertebral Facet Injections; Paravertebral Facet Joint Injections; Paravertebral Facet Joint Nerve Injections; Zygapophyseal injections; Lumbar Facet Blockade; Medial Branch blocks

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, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2016 Forward