Facet Joint Injections/ Medial Branch Blocks - (Effective Date - 2026-10-15) 7.01.116

By September 15, 2026 (30 days before effective date): Billing team must implement prior authorization requirements for all facet joint injections and medial branch blocks. REQUIREMENTS: (1) Update billing system to require prior authorization for all requests, flagging any claims without documentation of: conservative treatment for ≥4 weeks in past 3 months, axial pain persistence ≥3 months, imaging studies confirming no other etiology, and fluoroscopic or CT guidance; (2) Implement denial logic to reject claims missing required documentation elements per criteria sections I-VI; (3) Configure system to deny claims for: procedures without fluoroscopic/CT guidance, same-day billing with other invasive procedures (except TFESI with synovial cyst aspiration), more than 3 contiguous levels, levels above C2-C3 or below L5-S1, non-anesthetic/corticosteroid/contrast injectates, ultrasound-guided procedures, or procedures scheduled as 'series' without prior response evaluation; (4) Add validation rules to prevent billing >2 diagnostic injections at same level(s); (5) Require documentation of 80% pain relief response for second diagnostic injection and 50% pain relief for subsequent therapeutic injections; (6) For therapeutic injections (alternative to RF ablation), verify documentation of contraindication (pseudoarthrosis or implanted electrical device) and confirm 6-month minimum interval since prior injection; (7) Train billing staff, coders, and providers on new documentation requirements. Consequences: Claims submitted without compliance will be denied; retrospective denials will impact revenue.