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Anthem Blue Cross Blue Shield / Elevance (Commercial) · facet joint interventions

v1verified 2026-07-24manual-pull source

✓ conditional · commercial

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Facet-mediated AXIAL spinal pain (cervical or lumbar)
      • criteria:
        • pain pattern: predominantly axial, NOT radiculopathy/myelopathy/neurogenic claudication (exception: facet synovial cyst)
        • chronic pain min months: 3
        • severity: >=3/10 AND inability to perform >=2 ADLs/IADLs
        • regions: cervical (64490-64492) or lumbar (64493-64495) ONLY
        • no prior fusion at level: yes
  • investigational:
    • thoracic facet procedures (except C7-T1, T12-L1)
    • therapeutic intra-articular facet injection as default (allowed only for inflammatory arthropathy, denervation contraindicated, or synovial cyst)
    • cooled/pulsed/cryo/chemical/laser/endoscopic neurolysis; RF <80C
    • ultrasound guidance; facet prolotherapy/PRP; >1 spinal region per session
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • min duration weeks: 6
  • satisfied by:
    • failed >=6 weeks (PT + >=1 complementary modality)
    • contraindicated
  • modalities named:
    • physical therapy
    • pharmacologic
    • complementary (chiro/acupuncture/activity modification)
Trial
  • required: no
  • min duration days: not stated in the policy
  • success criteria: not stated in the policy
  • threshold is binding: no
Psychological evaluation
  • required: no
  • must clear: no
  • note posture: not required
Diagnostic blocks (facet protocol)
  • required before: radiofrequency neurotomy (64633-64636)
  • count: 2
  • anesthetic only: yes
  • relief threshold pct: 80
  • spacing: >=1 week apart; positive blocks valid for 6 months
Quantity limits
  • applies: yes
  • diagnostic per region per 12mo: 4
  • diagnostic per level per year: 2
  • levels per session: 2
  • rfa sessions per region per 12mo: 2
  • repeat rfa requires: >=50% relief + ADL improvement for >=6 months
  • excluded levels: C0-C1, C1-C2
Payor-specific notes

Carelon (Anthem) facet criteria. Dual medial branch blocks (anesthetic only, >=1 week apart, each >=80% relief, valid 6 months) gate RFA — the >=80% threshold MATCHES Medicare (WPS L38841/CGS L38773). KEY divergences from Medicare: a SIX-WEEK conservative floor (not months), a closed cervical/lumbar region list with an axial-pain + >=2-ADL severity gate, and therapeutic intra-articular facet injection barred as a default (RFA preferred). Thoracic facet procedures are investigational except C7-T1/T12-L1. From the actual fetched Carelon PDF.

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Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from Carelon MSK01-0626.1 (Interventional Pain Management, Anthem-delegated), not from the Medicare phrase. The dual anesthetic-only blocks are the RFA gate — document both dates.

.FACETANTHEM
.FACETANTHEM

Assessment: *** — facet-mediated chronic axial *** (cervical or lumbar only) pain present
>=3 months, rated >=3/10, with inability to perform >=2 ADLs/IADLs. The pain is
predominantly axial and is not radiculopathy, myelopathy, or neurogenic claudication (facet
synovial cyst excepted); the index segment has not been previously fused.

Medical necessity per Carelon MSK01-0626.1: conservative care has failed or was
contraindicated over >=6 weeks this episode — physical therapy plus at least one
complementary modality (chiropractic, acupuncture, or activity modification), with
medications *** . Two diagnostic medial branch blocks were performed at the same level(s)
*** , anesthetic only, >=1 week apart, each producing >=80% relief of the index pain
(*** and ***); positive blocks remain valid 6 months. Blocks were limited to one spinal
region per session and <=2 levels per session, within <=4 diagnostic blocks per region per
12 months and <=2 per level per year, under fluoroscopic or CT guidance.

Plan: Medial branch thermal RF neurotomy at the confirmed level(s) *** (64633/64634
cervical; 64635/64636 lumbar), within <=2 RFA sessions per region per rolling 12 months.
[If repeat:] the prior RFA gave >=50% relief with ADL improvement for >=6 months. Risks,
benefits, and alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (cervical/lumbar only; >=3/10 + >=2 ADL/IADL severity gate)
  • conservative-care line (>=6 WEEK floor, PT + >=1 complementary modality)
  • diagnostic-block line (anesthetic-only, >=1 wk apart, 6-month validity)
  • therapeutic IA facet posture (barred as default)
  • session/frequency limits (C0-C1/C1-C2 excluded; repeat gate adds ADL gain)

Cautions

  • Excluded levels/techniques: C0-C1 and C1-C2; cooled, pulsed, cryo, chemical, laser, and endoscopic neurolysis; RF below 80C; ultrasound guidance. Thoracic facet procedures are not covered except C7-T1 / T12-L1. Therapeutic intra-articular facet injection is not covered as a default — only for inflammatory arthropathy, when denervation is contraindicated, or for synovial cyst. Carelon Medical Benefits Management prior authorization required. Regenerate if `anthem-commercial-facet-joint.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: Carelon Medical Benefits Management

Provenance

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Change history

  • 2026-07-24commercial cells: re-verify 27 source PDFs by SHA-256 (Carelon/eviCore/UHC/Cigna) - all unchanged vs committed archive; last_verified -> 2026-07-24 3615c231f0
  • 2026-06-30Archive commercial source PDFs into sources/ + wire source_file/source_hash c5466694c8
  • 2026-06-28Add commercial Facet Joint cells: Anthem(Carelon), UHC, Cigna(eviCore) 962ec9816b