Flow Cytometry

Flow Cytometry
Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

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

History/Background and/or General Information

Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hemopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist.

Covered Indications
  1. HIV Infection

    The status of a Human Immunodeficiency Virus- (HIV) infected patient can be monitored by the analysis of the surface antigen CD4 (a T-cell receptor for HIV). This information can contribute to a prognosis as well as medical management for that individual (e.g., the need for AZT therapy or prophylaxis). Monitoring would be considered appropriate no greater in frequency than every 3 months. (When a patient is stable, especially during the long period of clinical latency, assays would be appropriate at a frequency less often. When the patient has an acute problem or therapy change, it may be necessary to perform the test at an increased frequency.)
  2. Leukemia or Lymphoma

    Leukemias and lymphomas may be analyzed in tissue, blood or marrow. Sometimes, flow cytometry may be performed on peripheral blood and fine needle aspirate material, thus, avoiding more invasive procedures for diagnosis. The presence or absence of antigens is determined using an antibody panel for appropriate diagnosis and classification. In the great majority of cases, 20 antibody determinations are sufficient to address diagnostic and prognostic concerns. This process is usually necessary at the initial diagnostic phase, for separate hematologic malignancies or when tumor is present in several anatomic sites. After this initial diagnostic phase, flow cytometry may be indicated to determine response to therapy.
  3. Organ Transplants

    Postoperative monitoring of organ transplants may be necessary to determine early rejection, immunosuppressive therapy toxicity or differentiation of infection from allograft rejection. The cells surface marker examined is CD3. This may require repeated analysis when symptoms are expressed for the above conditions by the transplant patient. 
  4. Carcinomas

    DNA analysis of tumor for ploidy and percent-S-phase cells may be necessary for a few selective patients with carcinomas. Information obtained from flow cytometry is useful when the obtained prognostic information will affect treatment decisions in patients with low stage (localized disease). This is usually performed only one time after a diagnosis has been made and before treatment is initiated.
  5. Primary Immunodeficiencies

    Primary immunodeficiencies (e.g., Lymphocyte disorders, Phagocyte disorders, Monocyte/macrophage disorder) are immune disorders that are present at birth. These conditions are quite rare. Diagnosis typically occurs at an early age due to recurrent infections with frequent failures. Initial evaluation for suspected primary immunodeficiencies includes physical exam, laboratory evaluation (e.g., CBC, platelet, WBC with differential, ESR) and may include skin testing. Flow cytometry is indicated for diagnostic purposes in the presence of established disease or when abnormal results are found in the initial evaluation.

    It is expected that the initial evaluation will contain a higher number of antibody examinations than a subsequent antibody examination.
Limitations

For frequency limitations please refer to the Utilization Guidelines section below.

Notice: This LCD imposes frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM, Medicare Program Integrity Manual, Pub.100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

    • 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 a malformed body member.
    • Furnished in a setting appropriate to the patient's medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient's medical needs.
    • At least as beneficial as an existing and available medically appropriate alternative.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.


CPT/HCPCS Codes

Group 1 Paragraph: 
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.



Group 1 Codes:
CODE DESCRIPTION
88182 Cell marker study
88184 Flowcytometry/ tc 1 marker
88185 Flowcytometry/tc add-on
88187 Flowcytometry/read 2-8
88188 Flowcytometry/read 9-15
88189 Flowcytometry/read 16 & >


References:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35032&ver=43&DocType=2&bc=AAIAAAAAAAAA&

Facial Prostheses

Facial Prostheses
Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. 

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions. 

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
  • The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  • The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  • Refer to the Supplier Manual for additional information on documentation requirements.

  • Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

A facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

AV – Item furnished in conjunction with a prosthetic device, prosthetic or orthotic

EY – No physician or other licensed health care provider order for this item or service

KM - Replacement of facial prosthesis including new impression/moulage

KN - Replacement of facial prosthesis using previous master model

LT - Left side

RT - Right side

HCPCS CODES:



Group 1 Codes:
CODE DESCRIPTION
A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ
A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES
A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
A4456 ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
A5120 SKIN BARRIER, WIPES OR SWABS, EACH
L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
L8048 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN
L8049 REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE INCREMENTS, PROVIDED BY A NON-PHYSICIAN
V2623 PROSTHETIC EYE, PLASTIC, CUSTOM

Facet Joint Interventions for Pain Management

Facet Joint Interventions for Pain Management

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. 
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
The spine is the most common source of chronic pain. Chronic spine pain poses a peculiar diagnostic and therapeutic challenge due to multiple pain sources, overlapping clinical features and nonspecific radiological findings. Facet joint interventions may be used in pain management for chronic neck and back pain arising from the paravertebral facet joints.
A paravertebral facet joint (also called zygapophysial joint or z-joint) represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. The facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints, right and left, at each spinal level.
The facet joints have been shown to be capable of causing axial spinal pain and referred pain in the extremities. The pathology of the pain source is due to facet joints being richly innervated by the nerve fibers from the medial branch of the dorsal ramus of spinal nerves. Each facet has a dual nerve supply. One exception is at the C2–C3 zygapophysial joint, which has a singular nerve supply from the third occipital nerve (the superficial medial branch of C3 dorsal ramus).
“Facet joint syndrome” is a term referring to pain at the joint between two vertebrae in the spine. Clinical signs of facet syndrome include local paraspinal tenderness; pain that is brought about or increased on hyperextension, rotation, and lateral bending; low back stiffness; absence of neurologic deficit; absence of root tension signs (non-radiating below the knee, absence of paresthesia). Cervical facet pain is often characterized by chronic headaches, restricted motion and axial neck pain which may radiate sub-occipitally to the shoulders or mid-back.
Facet joint interventions addressed in this policy include facet joint injections (intra-articular injections [IA] or medial branch nerve blocks [MBB]) and facet joint denervation to the cervical/thoracic and lumbar spinal regions. This policy does not address sacral injections or neurotomies. Providers should refer to the applicable American Medical Association (AMA) Current Procedural Terminology (CPT) Manual to assist with proper reporting of these services.
Facet Joint Injections (Diagnostic and Therapeutic) 

Facet injections, also known as facet blocks, may be given for diagnostic purposes to determine if the facet joint is the source of suspected spinal pain or for therapeutic purposes to treat facet pain that has been previously established. Imaging findings are of little value in diagnosing facet syndrome. It is usually a diagnosis of exclusion. Clinical signs alone cannot diagnose facet joint-mediated pain, but may be of value in selecting candidates for controlled diagnostic local anesthetic blocks. The response pattern to diagnostic facet joint injections has become the gold standard for diagnosing facet syndrome. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms.
The facet block procedure is an injection of a local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Please refer to the Local Coverage Article: Billing and Coding: Facet Joint Interventions for Pain Management (A56670), for instruction on reporting these services.
Facet Joint Denervation
Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic neck or back pain confirmed as originating in the facet joint’s medial branch nerve.
There are various methods that may be used in performing facet joint denervation. Percutaneous radiofrequency (RF) ablation (rhizotomy) is a minimally invasive procedure done with imaging guidance (fluoroscopy or CT per code descriptor) and involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. Conventional radiofrequency ablation (non-pulsed or continuous) applies thermal energy of typically 80 to 85 degrees Celsius. The terms radiofrequency ablation (RFA) and radiofrequency neurotomy are used interchangeably. Both terms refer to a procedure that destroys the functionality of the nerve using radiofrequency energy.
Non-thermal methods of denervation include chemical (chemodenervation), low-grade thermal energy (less than 80 degrees Celsius*), pulsed RF (PRF), laser neurolysis, and cryoablation. Please refer to the related billing and coding article for proper reporting of these services.
Covered Indications
1. Facet Joint Interventions:
Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria:
  • Duration of pain of at least three (3) months
  • Pain is intermittent or continuous with average pain levels of 6 or greater on a visual-numerical analogue pain scale (VNAS) of 0 to 10 (primary [index] pain), or functional disability
  • Documented failure to respond to conservative care such as nonsteroidal anti-inflammatory drugs (NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated)
  • History of pain that is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication
  • Physical examination with documented signs that the facet joint is the primary suspected source of pain 
  • 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
2. Diagnostic Facet Joint Injections:
The primary indication of diagnostic facet joint injection(s) is to confirm a clinical suspicion of facet syndrome. Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain to establish consistency of results due to high false positive rate of a single MBB injection.
  • For the first diagnostic MBB to be considered medically reasonable and necessary, the patient must meet the criteria outlined under indications for facet joint interventions.
  • A second confirmatory MBB is considered medically reasonable and necessary when ALL of the following are met:
    • The patient meets the criteria for the first diagnostic block; AND 
    • After the first diagnostic MBB, there must be a positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and activities of daily living (ADLs), or a change in technique can be considered.
Note: Intraarticular facet block(s) are considered reasonable and necessary as a diagnostic test only if medial branch blocks cannot be performed due to specific documented anatomic restrictions. These restrictions must be clearly documented in the medical record and made available upon request.
3. Therapeutic Facet Joint Injections:  
  • The first therapeutic facet joint injection is considered medically reasonable and necessary if the patient has had two (2) medically reasonable and necessary diagnostic MBBs with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs.
  • Subsequent therapeutic injections at the same anatomic site are considered medically reasonable and necessary when the patient has had at least 50% pain relief for at least three (3) months from the prior therapeutic injection. Repeat medically reasonable and necessary therapeutic injections at the same site of a previously treated facet joint may be done without additional diagnostic MBBs.
4. Facet Joint Denervation:
The thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows:
  • Initial thermal RF ablation:
    • After the patient has had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs; 
      OR
    • After the  patient has had at least one (1) medically reasonable and necessary therapeutic injection that provided at least 50% pain relief for at least three (3) months.
  • Repeat thermal facet joint RF ablation at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 50% improvement in pain for at least six (6) months. 
Limitations
The following are considered not reasonable and necessary and therefore will be denied:
  1. Facet joint interventions done without CT or fluoroscopic guidance are considered not reasonable and necessary. This includes facet joint interventions done without any guidance, performed under ultrasound guidance, or with Magnetic Resonance Imaging (MRI). Please refer to LCD L35094 Services That Are Not Reasonable and Necessary, for information on paravertebral facet injections with ultrasound guidance.
  2. Intraarticular and extraarticular facet joint prolotherapy are considered not reasonable and necessary.
  3. Non-thermal modalities for facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are considered not reasonable and necessary.
  4. General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Please refer to LCD L35049 Monitored Anesthesia Care for additional information. Frequent reporting of these services together may trigger focused medical reviews.
  5. It is not expected that patients will routinely present with pain in both cervical/thoracic and lumbar spinal regions. Therefore, the routine performance of facet joint interventions (both diagnostic and therapeutic) to both spinal regions may trigger focused medical review.
  6. It is not routinely necessary for multiple blocks (e.g., epidural block, sympathetic block) to be provided to a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or at different level[s]) must be clearly documented in the medical record. For example, performance of both paravertebral facet joint injection(s) and a transforaminal epidural injection (EI) at the same spinal level at the same encounter would not be expected unless a synovial cyst is compressing the nerve root. In this situation, EI may provide relief for the radicular pain while the facet cyst rupture allows nerve root decompression. For additional information on epidural injections, please refer to LCD L36920 Epidural Injections for Pain Management. Frequent reporting of multiple blocks on the same day may trigger focused medical review.
Place of Service (POS)
Medicare considers facet joint interventions reasonable and necessary when furnished in accordance with the accepted standards of medical practice, furnished in a setting appropriate to the patient’s medical needs and condition, meets but does not exceed the patient’s medical need, and when ordered and furnished by qualified personnel.
Facet joint intervention services must be performed in a place of service demonstrating the appropriate equipment (e.g., fluoroscopy, CT, medical emergency equipment). It is expected that all clinical staff maintain appropriate training to support their role as first responders to potential medical emergencies.
Provider Qualifications
Procedures listed and included in this LCD do not constitute anesthesia services. Evaluation, methods and techniques specified are not considered routine for surgical or perioperative anesthesia. Procedures to remedy facet pain originating from the medial branch nerve constitute surgical intervention of a diseased body part, for which evaluation, diagnosis and management must be established by a medical provider trained in the specific discipline. 
Services will be considered medically reasonable and necessary only if both of the following criteria are 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. Patient safety and quality of care mandate that healthcare professionals who perform injections or ablative techniques for treatment of specific nerve maladies and dysfunction are appropriately trained and are competent to perform all aspects of these procedures safely and effectively. The core curriculum of any training program should include the performance and management of the procedures addressed in this policy with documentation of trainee competency assessment included by formal examination and case history document review.
*At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, proficiency in evaluation, diagnosis and management of diseases necessitating the procedures, technical performance of the procedure and performing and interpreting medically reasonable imaging modalities required for procedure performance (imaging technique, contrast material use, and image interpretation) as well as the evaluation, diagnosis and management of potential complications from the intervention. 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. Only those settings with immediate availability of equivalent support services and personnel as those in a hospital will be considered appropriate for places of service for purposes of Medicare reimbursement.
Acceptable training or certification may be evidenced by any one of the following means:
  1. Satisfactory completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency and/or fellowship program in a relevant specialty (e.g., Interventional Pain Management, Anesthesiology); or
  2. Board certification in a relevant specialty by an American Board of Medical Specialties (ABMS) member board or equivalent AOA board; or
  3. Satisfactory completion of an accredited non-physician practitioner educational program that provides substantially equal content and scope as those mentioned in numbers 1 or 2 above and includes the minimum requirements stated in the preceding paragraph (see * above), with trainee competency directly assessed by state licensure examination or certification examination by a nationally recognized accrediting agency and maintenance of a case log of procedures performed; or
  4. 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.
  5. Be a credentialed physician or credentialed qualified non-physician practitioner staff member of a Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) certified hospital or outpatient center (or other appropriated CMS approved Certifying Organization) having credentialed active staff members meeting the criteria above.
Medicare is mindful that training and certification programs may evolve in order to meet the criteria set forth in 1-5 above. Medicare is also mindful that practitioners presently providing the services included within this LCD may require additional time in order to come into complete compliance with 1-5 above. For these reasons, Medicare adopts the following special criterion for a period of six months, at which time this criterion may be revised or deleted. For individuals who are presently providing interventional pain procedures and partially meet 1-5 above and who are actively endeavoring to complete requirements to fully comply with 1-5 above, Medicare will consider the sum of their training, certifications, and their practice experience for purposes of applying this policy.
Reimbursement for procedures utilizing imaging may be made to providers who meet training requirements for the procedures in this policy when permitted under relevant state professional practice acts. In addition, if applicable, all providers who seek Medicare payment for the procedures included in this policy must meet any applicable federal, state, or local licensing requirements and statutes for owning, operating, handling, or administering relevant ionizing radiation materials, equipment, and contrast.
Documentation of training and licensures must be made available to Medicare upon request.
This LCD imposes frequency limitations. For frequency limitations please refer to the Utilization Guidelines section below.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to Billing and Coding: Facet Joint Interventions for Pain Management, A56670, for applicable CPT codes and diagnosis codes.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD. 


Summary of Evidence

The American Society of Interventional Pain Physicians (ASIPP) Interventional Pain Management (IPM) Guidelines: An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations (2013)
  • Indications (per ASIPP): Facet joint interventions are applied in the cervical, thoracic, and lumbar regions. These include diagnostic, as well as therapeutic. Further, approaches include intraarticular injections, facet joint nerve blocks, conventional radiofrequency neurotomy, and pulsed radiofrequency neurotomy. The evidence is variable for each modality and for each region.
    • Diagnostic Facet Joint Nerve Blocks: Diagnostic facet joint injections may be performed either with an intraarticular approach or by blocking the facet joint nerves. However, the evidence is limited to poor for intraarticular injections, thus the evidence here described is based on diagnostic facet joint nerve blocks. The evidence for diagnostic accuracy of facet joint nerve blocks is good in the lumbar, thoracic, and cervical regions.
      • Common indications for diagnostic facet joint nerve blocks (per ASIPP) are as follows:
        • 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.
        • Moderate to severe pain causing functional disability.
        • Failure to respond to more conservative management, including physical therapy modalities with exercises, chiropractic management, and nonsteroidal anti-inflammatory agents.
        • Lack of evidence, either for discogenic or sacroiliac joint pain.
        • Lack of disc herniation or evidence of radiculitis.
    • Therapeutic Facet Joint Interventions: Therapeutic facet joint interventions are available for the cervical, thoracic, and lumbosacral regions. Therapeutic facet joint interventions include intraarticular injections, therapeutic facet joint nerve blocks, and radiofrequency neurotomy, either conventional or pulsed. The evidence is limited for these interventions. The evidence for intraarticular injections is limited for the cervical and thoracic regions and not available for the lumbar region. The evidence is fair to good for therapeutic facet joint nerve blocks, and fair for cervical and thoracic medial branch blocks. The evidence is good for radiofrequency neurotomy in the lumbosacral region, fair in the cervical region, and poor in the lumbar thoracic region. The evidence for pulsed radiofrequency is limited or not available. 

      Radiofrequency neurotomy is described as radiofrequency lesioning performed utilizing either a heat lesion or pulsed mode radiofrequency. A thermal radiofrequency neurotomy lesion for facet denervation is performed at 80° to 85°C. Clinically, a higher temperature allows for a larger lesion to be made. The size of the lesion is influenced by the vascularity of the surrounding tissue: the greater the vascularity of the tissue, the smaller the lesion. Overall, the mechanism of radiofrequency neurotomy is described as denaturing of the nerves. Consequently, with radiofrequency, the pain returns when the axons regenerate requiring repetition of the radiofrequency procedure. The pulsed mode radiofrequency is an application of a strong electric field to the tissue that surrounds the electrode and the temperature of the tissue surrounding the tip of the electrode does not exceed 42°C and heat is dissipated during the silent period.
      • Indications (per ASIPP) for therapeutic facet joint interventions are based on the diagnosis established with a positive response to controlled diagnostic blocks, either placebo or comparative local anesthetic blocks, with a criterion standard of 75% pain relief with ability to perform prior painful movements without significant pain.
  • Frequency of Interventions (per ASIPP):
    • In the diagnostic phase, a patient may receive 2 procedures at intervals of no sooner than 2 weeks or preferably 4 weeks, with careful judgment of response.
    • In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency would be 2 – 3 months or longer between injections, provided that greater than or equal to 50% relief is obtained for 2 months.
    • If the interventional procedures are applied for different regions, they may be performed at intervals of no sooner than one week or preferably 2 weeks for most types of procedures.
    • It is suggested that therapeutic frequency remain at least a minimum of 2 months for each region; it is further suggested that all the regions be treated at the same time provided that all procedures can be performed safely.
    • In the treatment or therapeutic phase, the interventional procedures should be repeated only as necessary according to the medical necessity criteria, and it is suggested that these be limited to a maximum of 4 times for local anesthetic and steroid blocks over a period of one year, per region.
    • Under unusual circumstances with a recurrent injury or cervicogenic headache, procedures may be repeated 6 times a year after stabilization in the treatment phase.
    • For facet joint neurolysis, the suggested frequency would be 6 months or longer (maximum of 2 times per year) between each procedure, provided that 50% or greater relief is obtained for 4 months.
    • The therapeutic frequency for medial branch neurotomy should remain at intervals of at least 6 months per each region with multiple regions involved. It is further suggested that all regions be treated at the same time, provided all procedures are performed safely.
  • Management of Low Back Pain:
    • Diagnostic Lumbar Facet Joint Nerve Blocks
      • The evidence for diagnostic lumbar facet joint nerve blocks is good with 75% to 100% pain relief as the criterion standard with controlled local anesthetic or placebo blocks.
      • Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain.
    • Therapeutic Lumbar Facet Joint Interventions
      • The evidence for lumbar conventional radiofrequency neurotomy is good, limited for pulsed radiofrequency neurotomy, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections.
      • Among the therapeutic facet joint interventions either conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks are recommended after the appropriate diagnosis with controlled diagnostic lumbar facet joint blocks.
  • Management of Neck Pain
    • Diagnostic Cervical Facet Joint Nerve Blocks
      • The evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with placebo or local anesthetic controlled diagnostic blocks.
      • Diagnostic cervical facet joint nerve blocks are recommended for the diagnosis of cervical facet joint pain.
    • Therapeutic Cervical Facet Joint Interventions
      • The evidence is fair for cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections.
      • Conventional radiofrequency neurotomy or therapeutic facet joint nerve blocks are recommended in managing chronic neck pain after the appropriate diagnosis from controlled diagnostic blocks.
  • Management of Thoracic Pain
    • Diagnostic Thoracic Facet or Zygapophysial Joint Nerve Blocks
      • The evidence for diagnostic accuracy of thoracic facet joint nerve blocks is good with a criterion standard of at least 75% pain relief with placebo or local anesthetic controlled diagnostic blocks.
      • The diagnostic thoracic facet or zygapophysial joint nerve blocks are recommended in the diagnosis of chronic thoracic pain.
    • Therapeutic Thoracic Facet or Zygapophysial Joint Nerve Blocks
      • The evidence is fair for therapeutic thoracic facet or zygapophysial joint nerve blocks, limited for radiofrequency neurotomy, and none for thoracic intraarticular injections.
      • Therapeutic thoracic facet or zygapophysial joint nerve blocks are recommended.
      • However, radiofrequency neurotomy and conventional radiofrequency neurotomy may be performed based on emerging evidence.
The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) 2014 Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3–6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. (Watters 2014)
The American Society of Anesthesiologists (ASA) Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Guidelines for Chronic Pain Management (2010) focus on the knowledge base, skills and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems.
  • Recommendations for joint blocks: Randomized controlled trials (RCT) report equivocal findings regarding the efficacy of facet joint steroid injections compared with facet saline injections regarding pain relief for patients with low back pain (LBP). However, studies with observational findings for facet joint injections indicate that pain scores are improved over baseline scores for assessment periods of 1-6 months.
    • Intraarticular facet joint injections may be used for symptomatic relief of facet-mediated pain.
    • Medial branch blocks may be used for the treatment of facet-mediated spine pain.
  • Recommendations for Ablative Techniques: The Task Force notes that other treatment modalities should be attempted before consideration of the use of ablative techniques.
    • Chemical denervation: Chemical denervation (e.g., alcohol, phenol, or high-concentration local anesthetics) should not be used in the routine care of patients with chronic non-cancer pain.
    • Cryoablation: Cryoablation may be used in the care of selected patients (e.g., postthoracotomy pain syndrome, low back pain (medial branch), and peripheral nerve pain).
    • Radiofrequency ablation: Conventional (e.g., 80°C) or thermal (e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief. Conventional radiofrequency ablation may be performed for neck pain. Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.
National Institute for Health and Care Excellence (NICE) guideline on Low back pain and sciatica in over 16s: assessment and management (2016). NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness.
Image guided facet joint injections:
  • Evidence statements
    • In people with low back pain there was clinical benefit for steroid injections compared with saline demonstrated in evidence from 1 study for both pain and function greater than 4 months (very low quality, n equal to 95), but no clinically important difference at equal to or less than 4 months.
    • Clinical benefit for steroid compared to hyaluronans was seen in pain in the short term (very low quality; 1 study; n equal to 59) with no clinically important difference between treatments in any other outcome reported at either short or long term.
    • There was no clinically important difference seen when a steroid injection was given in combination with biomechanical exercise compared to biomechanical exercise. Clinical benefit was seen however in pain at short and long term, but not in function, when injections of steroid and anaesthetic plus biomechanical exercise were compared to biomechanical exercise in a nonrandomised study (very low quality; n equal to 18).
  • Recommendations
    • Do not offer spinal injections for managing low back pain. The Guideline Development Group (GDG) agreed that health related quality of life, pain severity, function and psychological distress were the outcomes that were critical for decision making. Responder criteria (greater than 30% improvement in pain or function), adverse events, and healthcare utilization were also considered as important. Evidence was reported for all of outcomes except for psychological distress and healthcare utilization. For image guided facet joint injections, evidence was only available for pain, function and responder criteria. There was no evidence for any of the other outcomes.
  • Summary - Image guided facet joint injections
    • Overall the GDG agreed that there was no consistent good quality evidence to recommend the use of spinal injections for the management of low back pain. There was minimal evidence of benefit from injections, and reason to believe that there was a risk of harm, even if rare. The GDG consequently agreed that it was appropriate to recommend against the use of spinal injections for people with low back pain.
Radiofrequency denervation for facet joint pain
  • Evidence Statements
    • Radiofrequency denervation compared with placebo/sham for low back pain 
      • Evidence from 4 studies demonstrated clinical benefit in pain for radiofrequency denervation compared to placebo/sham at both the short and long term follow-ups of less than and greater than 4 months (low to moderate quality, n equal to 160). In contrast there was no difference in function between treatments at any time point. Conflicting evidence from 1 study for quality of life at less than 4 months follow-up showed clinical benefit for radiofrequency denervation compared to placebo/sham for the SF-36 domains of general health and vitality. Radiofrequency denervation was inferior to sham for the domains of mental health, pain and social function. There was no difference between treatments for the domain physical function (low quality, n equal to 81). Evidence from a single study reporting adverse events at less than 4 months follow-up demonstrated an increase in adverse effects for radiofrequency denervation in terms of the number of patients with moderate or severe treatment related pain (low quality, n equal to 79). There was no difference in other adverse events (change of sensibility and loss of motor function) at short term follow-up when radiofrequency denervation was compared to placebo/sham in the same study (very low quality). Additionally when compared with placebo/sham, benefit for radiofrequency denervation in responders to pain reduction measured by global perceived effect was demonstrated by 2 studies at both the less than and greater than 4 months follow-up time points although this was not seen for pain reduction measured by visual analogue scale (VAS) at less than 4 months reported by a single study (low quality, n equal to 111).
    • Radiofrequency denervation versus medial branch block
      • Evidence from a single study demonstrated clinical benefit in terms of pain for radiofrequency denervation compared to medial branch blocks at both the short and long term follow-ups of less than and greater than 4 months (very low quality, n equal to 100).
  • Recommendations
    • Consider referral for assessment for radiofrequency denervation for people with chronic low back pain when:
      • non-surgical treatment has not worked for them and
      • the main source of pain is thought to come from structures supplied by the medial branch nerve and
      • they have moderate or severe levels of localized back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral.
    • Only perform radiofrequency denervation in people with chronic low back pain after a positive response to a diagnostic medial branch block.
    • Do not offer imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation.
    • The GDG agreed that the features identified by the consensus group might be helpful in identifying those patients who may benefit from a radiofrequency denervation.
      • The features include: Increased pain unilaterally or bilaterally on lumbar para-spinal palpation
      • Increased back pain on 1 or more of the following:
        • extension (more than flexion)
        • rotation
        • extension/side flexion
        • extension/rotation AND
      • No radicular symptoms AND
      • No sacroiliac joint pain elicited using a provocation test.
    • Radiofrequency denervation is a technically demanding procedure and should only be performed by appropriately trained clinicians.
  • Research recommendation 
    The lumbar facet joints are pairs of joints that stabilize and guide motion in the spine. These joints and periarticular structures are well innervated by the medial branches of the dorsal rami. The prevalence of pain thought to be arising from the facet joints and periarticular structures in heterogeneous populations using local anaesthetic nerve blockade (medial branch block), where 75–100% pain relief is used as a criterion standard, is thought to be 25–40%. (Manchikanti, 2000). 

    The current guidance recommends that for people with low back pain who have failed to respond to conservative management, local anaesthetic medial branch nerve blockade to determine the presence or absence of a pain arising from the facet joints and periarticular structures may be offered. Those who experience significant but short term relief may then be offered a neurodestructive procedure called ‘radiofrequency denervation’ in an attempt to achieve longer term pain relief.

    Radiofrequency denervation has evolved as a treatment for spinal pain over the last 40 years and is a minimally invasive and percutaneous procedure performed under local anaesthesia or light intravenous sedation. Radiofrequency energy is delivered along an insulated needle in contact with the target nerves. This focused electrical energy heats and denatures the nerve. This process may allow axons to regenerate with time requiring the repetition of the radiofrequency procedure. 

    The duration of pain relief following radiofrequency denervation is uncertain. Data from randomised controlled trials suggests relief is maintained for at least 6-12 months but no study has reported longer term outcomes. Pain relief for more than 2 years would not be an unreasonable clinical expectation. 

    The de novo economic model undertaken for this guideline for radiofrequency denervation suggested that the treatment is likely to be cost effective provided the duration of effect exceeds 16 months.

    If radiofrequency denervation is repeated, we do not know whether the outcomes and duration of these outcomes are similar to the initial treatment. If repeated radiofrequency denervation is to be offered, we need to be more certain that this intervention is both effective and cost effective.

References:

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy

Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
Coverage Indications, Limitations, and/or Medical Necessity

Introduction:

The facet joints are potential causes of back pain. Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints. The MB nerves from the two adjacent dorsal rami innervate each joint. [Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve; and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.] Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. 

The diagnosis of facet-mediated spinal pain is difficult. History and physical exam may suggest, but cannot confirm, the facet pain as the source of pain. There are no imaging modalities (e.g. MRI, SPECT, CT, plain radiographs) or physiological tests (e.g. ROM testing) that have adequate diagnostic power to confidently distinguish the facet joint as the pain source. The absence of high-grade pain relief immediately following either intra-articular (IA) or MB nerve local anesthetic injections is helpful in excluding the facet joint as a pain source. Conversely, high-grade pain relief following dual medial branch blocks (MBBs) performed at separate sessions is the most reliable and valid method available of establishing a facet joint as the source of pain. Dual MBBs are necessary due to the unacceptably high false positive rate of single MBBs.

The efficacy of intraarticular facet joint steroid injection in the treatment of neck and back pain has not been established in the literature. However, emerging literature-based evidence and outcomes documented by provider suggest that intraarticular facet injections may provide limited benefit in carefully selected patients.

When dual MBBs provide immediate high-grade pain relief, thermal RF neurotomy has been used to denervate the facet joint in hopes of providing longer-term duration of relief. 

For purposes of this policy, a zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint. For ease of discussion, the term ‘facet joint’ will be used to connote the zygapophyseal joint throughout this document. A “session” is defined as all injections/blocks/RF procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and RF ablations.

Indications of Coverage:

  • At least 3 months of moderate to severe pain with functional impairment inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (if tolerated).
  • Predominant axial pain that is not associated with radiculopathy or neurogenic claudication.
  • Absence of non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, infection, or significant deformity.
  • Clinical assessment that implicates the facet joint as the putative source of pain.


General Procedure Requirements:

  • Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance.


Diagnostic Facet Joint Injections:

  • If, after the first MBB injection, the patient experiences ≥ 80% relief of their primary (index) pain, lasting a time period consistent with the local anesthetic used, the patient may undergo a second, confirmatory MBB.Since the technique of MBB relies on the patient’s perception of pain relief to establish the diagnosis, the patient must have sufficient pain immediately prior to the injection (generally ≥ 3/10 NPRS) to be able to detect significant improvement following the injection. Additionally, provocative maneuvers or positions which normally exacerbate index or typical pain must be determined before the injection.


Thermal Medial Branch Radiofrequency Neurotomy:

  • If adequate, but short term, pain relief occurs following MBB facet joint injections (see Diagnostic Facet Joint Injections), RF neurotomy may be a reasonable treatment option. Thermocoagulation with radiofrequency energy may achieve long-lasting pain relief via axonotmesis of the sensory afferent medial branch nerve. 
  • Dual MBBs are the ideal prognostic test to select patients for thermal RF neurotomy.
  • Only when dual MBBs provide ≥ 80% relief of the primary or index pain, with ability to perform previously painful movements consistent with the expected physiological effects of the agents utilized RF medial branch neurotomy be considered.
  • Repeat denervation procedures involving the same joint for the same region will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific ADLs documented for at least 5-6 months.
  • Repeat RF neurotomy to treat recurrent facet joint pain in a patient who has failed other conservative measures may be covered without repeating MBB injections if the patient has experienced significant and prolonged (≥ 5-6 months) relief of pain and improvement of function in the past following RF ablation.


Therapeutic Intraarticular (IA) Facet Injections:

  • Emerging evidence suggests that benefit from palliative care with IA injections may accrue in some patients and is potentially Medicare reimbursable. There is additional limited evidence that facet joint cyst rupture might be effective in a limited number of patients and is potentially Medicare reimbursable.


Therapeutic Facet Joint Nerve Blocks:
  • When dual MBBs provide greater than 80% relief of the primary or index pain consistent with the expected physiological effects of the agents utilized index pain with ability to perform previously painful movements, consistent with the expected physiological effects of the agents utilized, followed by at least 50% improvement for 6 weeks with pain and function, therapeutic facet joint nerve blocks may be considered.
  • Repeat therapeutic facet joint nerve block procedures involving the same joint or the same region will only be considered medically necessary if the patient experienced greater than 50% improvement of pain and improvement in patient specific ADLs documents for at least 2½ to 3 months.
  • Repeat therapeutic medial branch blocks to treat recurrent facet joint pain in patient who has failed other conservative measures may be covered without repeating MBB injections if the patient has experienced expected or prolonged relief of pain with improvement in function (2½ to 3 months) in the past following therapeutic facet joint injections.


Provider Qualifications:

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. 

Patient safety and quality of care mandate that healthcare professionals who perform Epidural Steroid Injections are appropriately trained and/or credentialed by a formal residency/fellowship program and/ or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program. If the practitioner works in a hospital facility at any time an/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics as well as proficiency in diagnosis and management of disease, the technical performance of the procedure and utilization of the required associated imaging modalities. 

Limitations of Coverage: 
  • Facet joint nerve injections for the treatment of acute, non-recurrent neck or back pain (<3 months’ duration) are not considered medically necessary.
  • New onset radiculopathy precludes coverage of facet blockade except radicular pain caused by a facet joint synovial cyst in the lumbar spine.
  • Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to anatomic restrictions.
  • A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, or facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.
  • For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any calendar year, involving no more than four (4) joints per session.
  • Repeat neurotomy procedures involving the same joint will only be considered medically necessary when the patient had ≥ 50% improvement of pain and documented improvement in patient specific ADLs documented for at least 6 months.
  • Repeat therapeutic facet joint or medial branch injections involving the same joint will only be considered medically necessary when the patient had ≥ 50% improvement of pain and improvement in patient specific ADLs for at least 3 months.
  • Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are therefore not reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.
  • Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.
  • Intraarticular or extraarticular facet joint prolotherapy is not covered.

    Frequency with criteria
    • Two diagnostic injections are allowed per region irrespective of the joints injected with maximum of 2 joints allowable per session per region.
    • No more than 4 therapeutic facet joint nerve blocks per year are reimbursable with 2 levels per region, per session after the appropriate documentation of 80% improvement with diagnostic blocks for the duration of the local anesthetic, and with a total relief and improvement of at least 50% of 6 weeks (including > 80% relief and > 50% relief). 
    • Two radiofrequency neurotomies per year involving 2 joints per region per session may be performed 2 times a year with appropriate documentation of relief with dual MBBs and 5 to 6 months of pain relief and functional improvement after a session.

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
CODE DESCRIPTION

64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT

64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


Group 2 Codes:
CODE DESCRIPTION

0213T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL

0214T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

0215T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

0216T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL

0217T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

0218T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)


References:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34993&ver=24&DocType=2&bc=AAIAAAAAAAAA&