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Cigna Healthcare (Commercial) · facet joint interventions

v2verified 2026-07-24pending changemanual-pull source

✓ conditional · commercial

Pending change: CMM-201/CMM-208 successor versions effective 2026-08-04 exist (not yet in force). Re-pull on/after that date.

Criteria checklist

0 of 6 ticked
Indications
  • enumerated: yes
  • covered:
      • name: Axial facet-mediated pain (C2-3 to L5-S1)
      • criteria:
        • pain pattern: axial, without untreated radiculopathy (exception: facet synovial cyst with concordant radiculopathy)
        • chronic pain min months: 3
        • conservative min weeks: 4
        • segment not fused: yes
  • investigational:
    • therapeutic facet injections (NMN except when RFA is contraindicated)
    • cooled RF, pulsed RF, cryo, chemical, laser, endoscopic rhizotomy
    • ultrasound-guided injection
    • basivertebral and SI-joint RF (experimental/investigational)
Conservative care
  • required: yes
  • min duration months: not stated in the policy
  • min duration weeks: 4
  • satisfied by:
    • failed >=4 weeks conservative (exercise/PT/chiro/NSAIDs)
    • contraindicated
  • modalities named:
    • exercise / physical therapy
    • chiropractic
    • NSAIDs
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 (CMM-208)
  • count: 2
  • relief threshold pct: 80
  • rfa intent: diagnostic blocks covered only if RFA is being considered
Quantity limits
  • applies: yes
  • diagnostic blocks per level: 2
  • levels: <=3 contiguous (<=6 if bilateral)
  • rfa sessions per level per 12mo: 2
  • rfa spacing: >=6 months apart
  • repeat rfa requires: >=50% relief lasting >=12 weeks
  • waveform: conventional thermal RF only
Payor-specific notes

Cigna delegates facet diagnostics to eviCore CMM-201 and RFA to CMM-208. Dual MBB/IA blocks each >=80% (matches Medicare) gate RFA, and diagnostics are covered only with RFA intent. STRICTER than Medicare on technology: Cigna covers CONVENTIONAL THERMAL RF only — cooled RF, pulsed RF, cryo, chemical, laser, and endoscopic rhizotomy are not covered (Medicare permits cooled RF); standalone therapeutic facet injections are NMN except when RFA is contraindicated. Repeat RFA needs >=50% relief lasting >=12 weeks. From the actual fetched eviCore PDFs. PENDING: 2026-08-04 successor versions.

Ticks are a documentation aid — nothing is stored; they reset on reload.

Dot phrase

Lean narrative A&P attestation. `***` = fill-in. Fully self-contained — rendered from eviCore CMM-201 (blocks) + CMM-208 (RFA), Cigna-delegated. Note the SPLIT gates: pain chronicity is

.FACETCIGNA
.FACETCIGNA

Assessment: *** — facet-mediated chronic axial *** pain from C2-3 to L5-S1, present >=3
months, without untreated radiculopathy (facet synovial cyst with concordant radiculopathy
excepted); the index segment has not been previously fused.

Medical necessity per Cigna eviCore CMM-201 and CMM-208: pain has been present >=3 months,
and >=4 weeks of conservative treatment within the past 3 months — exercise / physical
therapy, chiropractic, and NSAIDs — has failed or was contraindicated: *** . Two diagnostic
medial branch or intra-articular blocks were performed at the same level(s) *** , each
producing >=80% relief of the index pain (*** and ***), within the limit of <=2 diagnostic
blocks per level and undertaken with RFA as the intended endpoint. Guidance was fluoroscopic
or CT; ultrasound-guided injection is not covered.

Plan: Medial branch RF neurotomy using conventional thermal RF at the confirmed level(s)
*** (64633/64634 cervical-thoracic; 64635/64636 lumbar-sacral), across <=3 contiguous levels
(<=6 if bilateral), within <=2 RFA sessions per level per 12 months and >=6 months apart.
[If repeat:] the prior RFA gave >=50% relief lasting >=12 weeks. Risks, benefits, and
alternatives discussed; consent obtained.

Where this payor diverges from the Medicare baseline

  • diagnosis line (C2-3 to L5-S1 axial gate; >=3-month pain chronicity)
  • conservative-care line (pain >=3 MONTHS vs >=4 WEEKS treatment — split gates)
  • diagnostic-block line (covered only with RFA intent)
  • device/waveform line (conventional thermal RF only)
  • session/level limits (<=3 contiguous levels; repeat >=50% x >=12 wk)

Cautions

  • Conventional thermal RF ONLY — cooled RF, pulsed RF, cryo, chemical, laser, and endoscopic rhizotomy are not covered. Standalone therapeutic facet injections are not medically necessary except when RFA is contraindicated. eviCore / Evernorth prior authorization required. [!] CMM-201 / CMM-208 successor versions effective 2026-08-04 exist (not yet in force) — re-verify against the policy file on/after that date. Regenerate if `cigna-commercial-facet-joint.md` `version` advances past `source_version`.

Prior-auth pathway

  • required: yes
  • pathway: eviCore / Evernorth

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
  • 2026-07-23facet-joint/cigna v2: min_duration_months encoded chronicity, not the conservative floor eab5c027b3
  • 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