Is a repeat lumbar facet joint injection medically necessary for a patient with spondylosis without myelopathy or radiculopathy, who had significant relief from previous injections?

Medical Necessity Determination for Repeat Lumbar Facet Joint Injections

Primary Recommendation

Repeat lumbar facet joint injections at the same levels are NOT medically necessary in this case because the patient received bilateral L4-5 and L5-S1 facet joint injections in October 2022 with >80% relief lasting more than 3 years, and clinical policy explicitly states that additional sets of facet injections at the same levels and side are considered experimental and unproven. 1, 2

Critical Policy Violation

The clinical policy bulletin (CPB 0016) specifically addresses this scenario:

• Additional sets of facet injections or medial branch blocks at the same levels and side are considered experimental, investigational, or unproven because they have no proven value 1, 2
• The patient had bilateral L4-5, L5-S1 facet joint injections on 10/27/2022 with documented >80% relief lasting more than 3 years 1
• The current request is for the identical procedure at the identical levels (bilateral L4-5, L5-S1) 1

Evidence-Based Alternative: Radiofrequency Ablation

The appropriate next step for this patient is radiofrequency ablation (RFA) of the medial branch nerves, not repeat facet joint injections:

• The American Society of Anesthesiologists recommends conventional radiofrequency ablation of the medial branch nerves as the most effective treatment for confirmed facet-mediated pain when previous diagnostic or therapeutic injections have provided temporary relief 1, 2
• RFA provides moderate evidence for both short-term and long-term pain relief and is considered the "gold standard" for treating facetogenic pain 2
• The patient's own treatment plan from 10/6/2025 states: "will schedule for bilateral L4/5, L5/S1 lumbar FJ injection with progression to RFA if effective" 1
• The patient has already demonstrated >80% relief from facet injections lasting >3 years, which confirms facet-mediated pain and satisfies the diagnostic criteria for proceeding to RFA 1, 2

Why Repeat Injections Lack Evidence

Multiple high-quality studies demonstrate limited therapeutic value of repeat intraarticular facet joint injections:

• The Journal of Neurosurgery reports that facet joints are not the primary source of back pain in 90% of patients, with only 7.7% achieving complete relief from facet injections 3, 4, 2
• Moderate evidence indicates that facet joint injections with steroids are no more effective than placebo injections for long-term relief of pain and disability 4, 2
• A systematic review found limited evidence for intraarticular facet injections as a treatment modality, though medial branch blocks showed better therapeutic efficacy 1

Clinical Reasoning for This Patient

The patient's previous exceptional response (>80% relief for >3 years) is actually an argument FOR radiofrequency ablation, not repeat injections:

• When a patient achieves ≥50% pain relief for at least 2 months after a first injection, this suggests benefit from steroid effect and may warrant consideration of alternative approaches 3
• The patient's >80% relief lasting >3 years far exceeds typical duration and confirms the facet joints as pain generators 1, 2
• This diagnostic confirmation should lead to definitive treatment (RFA) rather than repeating a temporary intervention 2

Important Caveats About Medial Branch Blocks vs. Intraarticular Injections

If repeat injections were to be considered, medial branch blocks would be more appropriate than intraarticular facet joint injections:

• Medial branch blocks show better evidence for therapeutic efficacy, with studies showing significant pain relief for up to 44-45 weeks, with each injection providing approximately 15 weeks of relief 1, 2
• The evidence for lumbar intraarticular facet joint injections is only moderate for short- and long-term pain relief 5
• Multiple injections of medial branch blocks at defined intervals can provide long-term pain relief, whereas repeat intraarticular injections lack this evidence 5

Conservative Treatment Documentation

While the patient appears to meet most initial criteria for facet joint interventions, the documentation shows:

• The patient has taken Naproxen 500 mg twice daily for approximately 20 years 1
• The patient reports "some physical therapy" and documentation states completion of formal PT with continuation of home exercise program for >6 weeks 1
• However, the patient is now 3 years post-injection, and the current pain represents recurrence after prolonged relief, not failure of initial conservative management 1

Appropriate Clinical Pathway

The evidence-based treatment algorithm for this patient should be:

1. Confirmed facet-mediated pain (already established by >80% relief from previous injections lasting >3 years) 1, 2
2. Proceed directly to radiofrequency ablation of bilateral L4-5 and L5-S1 medial branch nerves 1, 2
3. Skip repeat diagnostic or therapeutic facet joint injections as they are considered experimental at the same levels 1, 2

Safety Considerations

• Facet joint injections are generally safe procedures with low complication rates 3
• The most common side effects include injection-site pain, vasovagal reactions, facial flushing, and transient increases in pain 3
• However, safety alone does not establish medical necessity when more effective alternatives exist and policy explicitly excludes repeat injections 1, 2