Thursday, March 9, 2017

cpt 64635, 64636 - Lumbar facet blockade


Group 1 Codes:
64493 Inj paravert f jnt l/s 1 lev
64494 Inj paravert f jnt l/s 2 lev
64495 Inj paravert f jnt l/s 3 lev
64635 Destroy lumb/sac facet jnt
64636 Destroy l/s facet jnt addl

Group 2 Paragraph: The CPT codes listed below will be denied as investigational.

Group 2 Codes:
0216T Njx paravert w/us lumb/sac
0217T Njx paravert w/us lumb/sac
0218T Njx paravert w/us lumb/sac

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity


For the purposes of this LCD, a zygapophyseal (ZP) joint ‘level’ refers to the intra-articular joint or the two medial branch nerves that innervate that ZP joint. 

Additionally, cervical and thoracic facet blockade are not addressed in this LCD, however, are covered when reasonable and necessary.

The spinal facet joints are probable causes of somatic low back pain. The facet, or ZP, joint is a paired diarthrodial articulation at the junction of the superior and inferior articular processes of adjacent vertebrae. Facet joints are innervated by the medial branches of the dorsal rami of the segmental nerves. The medial branch nerves from two adjacent dorsal rami innervate each joint.

Lumbar facet blockade techniques are used in the diagnosis and/or treatment of chronic low back pain (LBP) and may alleviate LBP associated with:
Hypertrophic arthropathy of the facet joints;
Post-traumatic injury states; and/or
Suspected motion segment instability/hypermobility or 
pseudoarthrosis following fusion.
History and physical exam cannot discriminate facet pain from other sources 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 incriminate the facet joint as the pain generator.

Historically, both intra-articular blocks (IA) and medial branch blocks (MBB) have been used for diagnosis and treatment of LBP due to facet arthropathy. An optimal diagnosis of facet mediated pain requires dual medial branch blocks (DMBB). 

The efficacy of IA in the treatment of LBP has not been established in the literature; therefore, this LCD does not allow coverage of therapeutic IA. 

This LCD allows coverage of diagnostic IA and diagnostic DMBB. 


Diagnostic IA or DMBB
Diagnostic lumbar facet joint nerve blocks are recommended in patients with suspected facet joint pain when all of the following criteria are met:

Patients suffering with somatic or non-radicular low back and lower extremity pain, with duration of pain of at least 3 months with no definitive radiological cause.

Average pain levels are of greater than 6 on a scale of 0 to 10.

Pain is at least intermittent or continuous causing functional disability. The functional disability must be documented in the medical record.

Condition has failed to respond to more conservative management, including physical therapy modalities, chiropractic management and medication management. This criterion may be waived if documentation supports inability to undergo the above outlined conservative management.

A positive diagnostic response is based on the following evidence:

Patient has met the above indications.
Patient responds positively to controlled local anesthetic blocks either with placebo control or comparative local anesthetic blocks with appropriate response to each local anesthetic of < 1 mL for each nerve or joint.
Almost complete relief of pain, as indicated by a post procedure pain score of 3 or less on a scale of 0 to 10, and the ability to perform previously painful movement.

Therapeutic DMBB

A DMBB therapeutic injection may be indicated when there has been:

A positive diagnostic response, or

A previous positive therapeutic response.

A positive therapeutic response is described as:

Persistent pain relief for a minimum of six (6) weeks of = (greater than or equal to) 50% with the continued ability to perform previously painful maneuvers.

Facet Destruction by Neurolytic Agent

If adequate but short term relief occurs from prior therapeutic DMBB, then facet destruction by neurolytic agent may be a reasonable treatment option in those with a secure diagnosis of facet pain. 

The effects of appropriately performed facet destruction should last at least six (6) months or more and, in some cases, are permanent. Repeat facet destruction procedures of the same level can be considered reasonable and necessary with appropriate documentation in the medical record of return of pain and loss of function.

Care of the patient with chronic LBP requires a multidisciplinary (e.g., physical therapy, chiropractic treatment, home exercise program, etc.) treatment program. 

Lumbar facet blockade for the treatment of acute back pain (less than 3 months’ duration) is considered not reasonable and necessary. 

An injection session is defined as all facet injections administered during a 24 hour period for a specific date of service in the lumbar region. Therefore, 

In the first year, up to six (6) facet injection sessions may be performed in the lumbar region: up to two (2) diagnostic and up to four (4) therapeutic.

In the following years, up to four (4) therapeutic facet injection sessions may be performed in the lumbar region.

A maximum of two (2) facet destruction sessions per nerve level per year may be performed in the lumbar region. The rationale for more frequent facet destruction must be documented in the medical record.

Performance of more than one type of injection for pain treatment, such as epidural, sacroiliac joint injections or lumbar sympathetic injections, on the same day as diagnostic lumbar facet blockade is not considered reasonable and necessary.

IA, DMBB (diagnostic and/or therapeutic) or neurolysis must be performed under fluoroscopic or computed tomographic (CT) guidance; ultrasonic guidance (CPT 0216T, 0217T, 0218T) will be denied as investigational.

Injections into the paravertebral musculature must not be billed as IA or DMBB.

Clinicians performing these services must have appropriate training in interventional pain management and radiographic guidance. Documentation of this training must be maintained at the site of practice.

The following are not covered:

Pulsed radiofrequency lesioning.
Intra-articular or extra-articular facet joint prolotherapy.

Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

No comments:

Post a Comment

Popular Posts