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OPD Procedure: Facet Joint Interventions for Pain Management

The primary purpose of facet joint interventions is to relieve moderate to severe chronic pain.

Medical Necessity

Services are considered reasonable and medically necessary in patients who meet ALL of the following criteria:

First Diagnostic Criteria:

Moderate to severe chronic neck or low back pain persistent for at least a minimum of 3 months
Documented failure to respond to noninvasive conservative management
Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
Clinical assessment or radiological study that could explain the source of the patient's pain which is not related to a facet pathology, including but not limited to fracture, tumor, infection, or significant deformity

Second Diagnostic Criteria:

Meet all indications for first diagnostic criteria
Consistent positive response of at least 80% relief with primary index pain consistent with the agent used

Therapeutic Facet Joint Intraarticular (IA) Procedures Criteria:

Has had 2 medically reasonable and necessary diagnostic facet joint procedures with each providing a consistent 80% relief of primary pain index with the same agent used
At the same anatomic site, there is a result of at least 50% consistent pain relief for at least 3 months or 50% improvement in ADL functioning
Documentation that explains why the patient cannot receive a radiofrequency ablation procedure

General Documentation Requirements

Current H&P, office visit note, or physician progress note
- Documentation of patient complaints, signs and symptoms, etc.
- Condition affecting functionality, etc.
Same pain/measurement scale used before and after a procedure
Documentation on conservative treatments tried and their results
If necessary, documentation on previous facet joint interventions and their results
- Documentation on agent used
If necessary, documentation on why an MBB cannot be performed
If necessary, documentation on reasons why a radiofrequency ablation could not be performed
Supporting radiological imaging

Prior Authorization Request Form

Prior Authorization OPD: Facet Joint Interventions