An initial facet injection (intra-articular and medial branch block) from C2-3 to L5-S1 is considered medically necessary for the diagnosis of facet pain in persons with severe chronic neck and back pain that limits daily activities and has lasted more than 3 months despite six or more weeks of conservative treatment (including, systemic medications, and/or physical therapy), with symptoms suggestive of facet joint syndrome (symptoms of facet joint syndrome include absence of radiculopathy, pain that is aggravated by extension, rotation or lateral bending of the spine and is not typically associated with any neurological deficits), where facet mediated pain is confirmed by provocative testing on physical examination (to confirm that pain is exacerbated by extension and rotation), imaging studies suggest no other obvious cause of pain (such as fracture, tumor, infection, or significant extraspinal lesion), and radiofrequency facet neurolysis is being considered. Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain provided, however, that only one invasive modality or procedure will be considered medically necessary at a time.
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