Updated Medicare local coverage determination for facet joint injections for Medicare Plus Blue^SM and BCN Advantage^SM members, starting April 25, 2021

For dates of service on or after April 25, 2021, the updated Medicare local coverage determination for facet joint interventions for pain management (L38841) applies.

The changes to the LCD include, but aren't limited to, the following:

• The patient's baseline pain and function must be documented using pain and disability scales. The scales must be updated after each diagnostic procedure and at each follow-up appointment.
• The second diagnostic medical branch block must be performed at least 2 weeks after the first block.
• Therapeutic facet joint injections are covered only when the patient is not a candidate for radiofrequency ablation. Rationale must be documented.
• All procedures are limited to 1 or 2 levels per session.
  • For diagnostic / therapeutic facet joint injections, no more than 4 sessions are allowed per region (cervical / thoracic and lumbar) during a rolling 12-month period, for an absolute maximum of 8 injections.
  • For radiofrequency ablation, no more than 2 sessions are allowed per region during a rolling 12-month period, for an absolute maximum of 4 injections.
• Only 1 spinal region can be treated per session (cervical / thoracic or lumbar).
• Multiple types of interventions may not be performed on the same day. For example, epidural steroid injections, facet joint infections and trigger point injections cannot be performed on the same day.
• Further exclusions on facet joint injections include intra-facet implants, facet joint interventions after anterior lumbar interbody fusion, and diagnostic procedures at the same level as prior successful radiofrequency ablation.

As a reminder

When making authorization determinations for Medicare Plus Blue and BCN Advantage members, TurningPoint applies Medicare national coverage determinations / Medicare local coverage determinations.

If there is no Medicare NCD / LCD, TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint agreed on.

Additional information

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

• Blue Cross commercial* — All fully insured groups, select self-funded groups and all members with individual coverage
• Medicare Plus Blue members
• BCN commercial members
• BCN Advantage members

*To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see "How do I know if I need to request prior authorization from TurningPoint for members who have coverage through Blue Cross commercial plans?" in the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network