May 22, 2024

State of Alabama
Press Release: Medicaid

Implementation of Prior Authorization for Spinal Facet-Joint Interventions

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TO:    ALL Providers

 

RE:   Implementation of Prior Authorization for Spinal Facet-Joint Interventions

 

Prior Authorization: Effective for dates of service on or after May 1, 2024, the Alabama Medicaid Agency (Medicaid) updated the prior authorization (PA) program to include facet-joint intervention procedures.  Specifically, procedure codes 64490-64495 and 64633-64636, require PA prior to services rendered when performed in the office, outpatient hospital, ambulatory surgical center, or pain management clinic settings. 

 

All the following requirements must be met for medical necessity to be determined:

Diagnostic injection:

Denervation:

Therapeutic injection:

1.     ≥ 3 months of documented back or neck pain that interferes with the recipients ‘activities of daily living (ADLs).

2.     ≥ 6 weeks of conservative therapy (e.g., physical therapy, home exercise program, activity modification) with documented failure of pain to respond to treatments.

3.     ≥ 3 weeks NSAID therapy or NSAID is contraindicated or was not tolerated.

4.     Clinical findings suggestive of facet joint syndrome as evidenced by the absence of nerve root compression.

5.     Imaging studies suggestive of no other cause for the pain (e.g., disc herniation, radiculitis, discogenic or sacroiliac pain).

6.     No prior spinal fusion surgery in the vertebral level being treated.

7.     A facet joint denervation intervention is being considered.

1.     The recipient has had up to two medically reasonable and necessary diagnostic facet joint injections with each one providing a consistent minimum of 80% pain relief.

2.     ≥ 3 months of documented back or neck pain that interferes with the recipients’ ADLs.  

3.     ≥ 6 weeks of conservative therapy (e.g., physical therapy, home exercise program, activity modification) with documented failure of pain to respond to treatments.

4.     ≥ 3 weeks NSAID therapy or NSAID is contraindicated or was not tolerated.

5.     Clinical findings suggestive of facet joint syndrome and imaging studies suggestive of no other cause for the pain (e.g., fracture, tumor, infection, disc herniation, radiculitis, discogenic or sacroiliac pain, etc.).

6.     No prior spinal fusion surgery in the vertebral level being treated.

 

1.     Recipient must meet all the criteria for denervation.

2.     Documentation of why the recipient is not a candidate for denervation.

3.     The recipient has had 2 medically reasonable and necessary diagnostic facet joint injections with each providing a consistent minimum of 80% pain relief.

4.     Subsequent therapeutic injections at the same anatomic site results in at least 50% pain relief for at least three months from the prior therapeutic injection or at least 50% improvement in the ability to perform ADLs as compared to baseline measurements.

 

For general information regarding prior authorization, refer to the Provider Billing Manual - Chapter 4, Obtaining Prior Authorization.

 

Documentation Requirements: Providers should include the following documentation with their facet-joint interventions PA request:

  • Clear indication of what is being requested
  • History and physical 
  • Physician orders and progress notes 
  • Diagnostic test results 
  • Pain history to include location, severity and duration 
  • Evidence of failed conservative management 
  • Patient response to prior facet-joint interventions, if applicable
  • Completed Alabama Prior Review and Authorization Request Form 342

 

Frequency Limitations: Effective for dates of service on or after May 1, 2024, Medicaid established the following frequency limitations for spinal facet-joint intervention procedures when performed in the office, outpatient hospital, ambulatory surgical center, or pain management clinic settings. 

 

The following Diagnostic Facet-Joint Injection procedure codes will be limited to one spinal region (e.g., cervical/thoracic, or lumbar/sacral) per session, with a maximum of two joints per session. In total, each covered spinal region is allowed four sessions per calendar year:

 

Procedure Code

Procedure Code Short Descriptor

PA Required

   64490

INJ PARAVERT F JNT C/T 1 LEV

Yes

64491*

INJ PARAVERT F JNT C/T 2 LEV

Yes

   64493

INJ PARAVERT F JNT L/S 1 LEV

Yes

64494*

INJ PARAVERT F JNT L/S 2 LEV

Yes

                       

Note: Codes with * are not applicable to outpatient hospital and ambulatory surgical centers.

 

The following Facet-Joint Denervation procedure codes will be limited to one spinal region (e.g., cervical/thoracic, or lumbar/sacral) per session, with a maximum of four joints per session. In total, each covered spinal region is allowed two sessions per calendar year:

 

Procedure Code

Procedure Code Short Descriptor

PA Required

64633

DESTROY CERV/THOR FACET JNT

Yes

64634

DESTROY C/TH FACET JNT ADDL

Yes

64635

DESTROY LUMB/SAC FACET JNT

Yes

64636

DESTROY L/S FACET JNT ADDL

Yes

 

The following Therapeutic Facet-Joint Injection procedure codes are non-covered and describe a third and additional level. Therapeutic Facet-Joint injections are medically necessary only if a recipient is not a candidate for denervation and utilize the same restrictions as diagnostic injections:

 

Procedure Code

Procedure Code Short Descriptor

PA Required

64492*

INJ PARAVERT F JNT C/T 3 LEV

Yes

64495*

INJ PARAVERT F JNT L/S 3 LEV

Yes

                        

Note: Codes with * are not applicable to outpatient hospital and ambulatory surgical centers.

 

See LCD L34892 – Facet Joint Interventions for Pain Management for more information.

 

A 45-day grace period is permitted for providers to retroactively submit PA requests. After July 1, 2024, all PA requests must be obtained prior to services rendered.

 

For billing questions, call the Gainwell Technologies Provider Assistance Center at 1-800-688-7989. Send policy questions to Medicaid’s Physician Program at Physicians.Program@medicaid.alabama.gov.





The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2024 American Medical Association and © 2024 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.



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