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Facet Joint Injections/ Medial Branch Blocks 7.01.116
Act
by Oct 15, 2025
Effective date
Oct 15, 2025
Identified
Jul 16, 2026
Summary
Excellus BlueCross BlueShield implemented a comprehensive new policy (effective Oct 15, 2025) establishing strict criteria for facet joint injections and medial branch blocks, including diagnostic requirements (3+ months pain, 4+ weeks conservative treatment), imaging studies to rule out other causes, limits of 3 levels per session, and prohibition of certain injectates (biologics) and guidance methods (ultrasound). Therapeutic injections are now only reimbursable as alternatives when radiofrequency ablation is contraindicated, and all procedures must use fluoroscopic or CT guidance.
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What to do
by Oct 15, 2025 · 11 steps
01Billing and clinical teams must implement the following.
02Update 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.
03Providers must document that no more than 3 facet joint levels are injected per session and confirm the spinal motion segment is not posteriorly fused.
04Modify 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).
05Stop billing/authorizing any facet joint injections performed without fluoroscopic or CT guidance—ultrasound-guided procedures are now investigational and non-covered.
06Prohibit billing for biologics (PRP, stem cells, amniotic fluid) in facet joint injections—these are investigational.
07Implement 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).
08Flag and require second diagnostic injection confirmation showing 80% pain relief before authorizing therapeutic injections.
09Ensure subsequent therapeutic injections document 50% relief for 12+ weeks from prior injection and are spaced 6+ months apart.
10Train billing staff on the related policy 7.01.42 for radiofrequency ablation requests.
11Claims submitted without meeting documented criteria will be denied.
Original notice
Facet Joint Injections/ Medial Branch Blocks 7.01.116
excellusbcbs.com · Always check the source before changing claims.
Related changes
See all Excellus BlueCross BlueShield changes →Facet Joint Injections/ Medial Branch Blocks - (Effective Date - 2026-10-15) 7.01.116MediumEffective Oct 15, 2026 · Bone & Joints (Orthopedic)Facet Joint Injections/ Medial Branch Blocks 7.01.116HighEffective Oct 15, 2025 · Bone & Joints (Orthopedic)Browse every Excellus BlueCross BlueShield change in the policy list