National Imaging Associates, Inc. Clinical guidelines Original Date: July 1, 2015 FACET JOINT INJECTIONS OR BLOCKS Page 1 of 4 “FOR FLORIDA BLUE MEMBERS ONLY” CPT Codes: Last Review Date: May 28, 2015 Cervical/Thoracic Region: 64490 (+ 64491, +64492) Lumbar/Sacral Region: 64493 (+64494, +64495) Medical Coverage Guideline Number: Last Revised Date: 02-61000-30 Responsible Department: Implementation Date: July 2015 Clinical Operations

“FOR FLORIDA BLUE MEMBERS ONLY”

INTRODUCTION

Facet joints (also called zygapophysial joints or z-joints), are posterior to the vertebral bodies in the spinal column and connect the vertebral bodies to each other. They 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 those with chronic spinal 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 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 candidates for controlled local anesthetic blocks of either the medial branches or the facet joint itself. This is an established tool in diagnosing facet joint syndrome.

Facet joint interventions are used in the treatment of pain in certain individuals with a confirmed diagnosis of facet joint pain. Interventions include intra-articular injections and medial branch nerve blocks in the affected region. Facet joint injections or medial branch nerve blocks require guidance imaging.

CLINICAL INDICATIONS:

Facet joint injection meets the definition of medical necessity when ALL of the following are met:

1—Facet Joint Injections_Blocks – Florida Blue Proprietary  Disabling, non-radicular low back (lumbosacral) or neck (cervical) pain*, suggestive of facet joint origin as documented in the medical record based upon: o History, consisting of mainly axial or non-radicular pain, AND o Physical examination, with positive provocative signs of facet disease (pain exacerbated by extension and rotation, or associated with lumbar rigidity)  Lack of evidence for discogenic or sacroiliac joint pain  Lack of disc herniation or evidence of radiculitis  Intermittent or continuous pain with average pain levels of ≥ 6 on a scale of 0 to 10, or functional disability  Duration of pain of at least 2 months  Failure to respond to conservative non-operative therapy*  Injection is performed with fluoroscopic or CT guidance

*Thoracic facet joint injection is considered experimental or investigational. Data in published medical literature are inadequate to permit scientific conclusions on long-term and net health outcomes.

Facet joint injection performed with ultrasound guidance is considered experimental or investigational. The evidence is insufficient to permit conclusions on efficacy and net health outcomes.

Frequency of facet joint injections:

 There must be a minimum of 14 days between injections  There must be a positive response of ≥ 50% pain relief and improved ability to perform previously painful movements  Maximum of 3 procedures per region every 6 months (lumbar and sacral are considered as one region)  If the procedures are applied for different regions, they may be performed at intervals of no sooner than 2 weeks for most types of procedures  Maximum of 3 levels injected on same date of service  Radiofrequency neurolysis procedures should be considered in those with positive facet blocks (with at least 50% pain relief and ability to perform prior painful movements without any significant pain)

*Conservative non-operative 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. ** A home exercise program (HEP) must consist of the following two elements: 1. Information on an exercise prescription/plan is provided to the member 2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises). NOTE: member inconvenience or noncompliance without explanation does not constitute inability to complete a HEP.

2— Facet Joint Injections_Blocks – Florida Blue Proprietary Contraindications for facet joint injections include:  History of allergy to contrast administration, local anesthetics, steroids, or other drugs potentially utilized  Hypovolemia  Infection over puncture site  Bleeding disorders or coagulopathy  Inability to obtain percutaneous access to the target facet joint  Progressive neurological disorder which may be masked by the procedure  Pregnancy  Spinal infection  Acute Fracture

BILLING/CODING INFORMATION:

CPT Coding: 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) 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic, single level (investigational) 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (investigational) 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) (investigational)

3— Facet Joint Injections_Blocks – Florida Blue Proprietary 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level (investigational) 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) (investigational) 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) (investigational)

ICD-9 Diagnoses Codes That Support Medical Necessity: (if position statement criteria are met) 719.48 Pain in joint involving other specified sites 721.0 Cervical spondylosis without myelopathy 721.2 Thoracic spondylosis without myelopathy 721.3 Lumbosacral spondylosis without myelopathy 721.41 Spondylosis with myelopathy, thoracic region 721.42 Spondylosis with myelopathy, lumbar region 722.81 Post-laminectomy syndrome of cervical region 722.82 Post-laminectomy syndrome of thoracic region 722.83 Post-laminectomy syndrome of lumbar region 723.1 Cervicalgia 724.1 Pain in thoracic spine 724.2 Lumbago 724.8 Other symptoms referable to back V58.61 Long-term (current) use of anticoagulants (Use only as a supplemental code in addition to primary diagnosis, when anticoagulant therapy has been discontinued to facilitate therapeutic injections for pain management)

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15) M25.50 – M25.579 Pain in unspecified joint M47.14 – M47.18 Other spondylosis with myelopathy M47.812 – M47.817 Spondylosis without myelopathy or radiculopathy M47.892 – M47.897 Other spondylosis M47.9 Spondylosis, unspecified M54.2 Cervicalgia M54.5 Low back pain M54.6 Pain in thoracic spine M96.1 Postlaminectomy syndrome, not elsewhere classified Z79.01 Long-term (current) use of anticoagulants

4— Facet Joint Injections_Blocks – Florida Blue Proprietary