Facet Joint Injections/ Medial Branch Blocks 7.01.116

By October 15, 2025: Billing and clinical teams must implement the following: (1) Update billing system and prior authorization software to enforce the new diagnostic criteria requirements—documentation must prove 3+ months of pain, 4+ weeks of conservative treatment, and imaging studies ruling out other causes before claims are processed; (2) Providers must document that no more than 3 facet joint levels are injected per session and confirm the spinal motion segment is not posteriorly fused; (3) Modify encounter templates and order sets to require providers to document which spinal levels are being treated (cervical C2-C3 to L5-S1 only, excluding atlanto-occipital and atlanto-axial joints); (4) Stop billing/authorizing any facet joint injections performed without fluoroscopic or CT guidance—ultrasound-guided procedures are now investigational and non-covered; (5) Prohibit billing for biologics (PRP, stem cells, amniotic fluid) in facet joint injections—these are investigational; (6) Implement logic to deny claims for more than 2 diagnostic injections at the same level unless they are therapeutic injections for radiofrequency contraindications (pseudoarthrosis or implanted electrical devices); (7) Flag and require second diagnostic injection confirmation showing 80% pain relief before authorizing therapeutic injections; (8) Ensure subsequent therapeutic injections document 50% relief for 12+ weeks from prior injection and are spaced 6+ months apart; (9) Train billing staff on the related policy 7.01.42 for radiofrequency ablation requests. Claims submitted without meeting documented criteria will be denied.