Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Radiofrequency Facet Denervation (also known as non-pulsed radiofrequency denervation, facet neurotomy, facet rhizotomy, or articular rhizolysis) of cervical facet joints (C2-C3 thru C7-T1 vertebrae) and lumbar facet joints (T12-L1 thru L5-S1 vertebrae) may be considered medically necessary when
ALL
of the following criteria are met. No prior spinal fusion surgery in the vertebral level being treated;
and
-
Disabling low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical, and radiographic evaluations; and the pain is not radicular;
and
-
Pain has failed to respond to three (3) months of conservative management, which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program;
and
-
A successful trial of controlled diagnostic medial branch blocks consisting of two (2) separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in at least a 50% reduction in pain for the duration of the local anesthetic used (e.g., three (3) hours longer with bupivacaine than lidocaine);
and
- No therapeutic intra-articular injections (i.e., steroids, saline, or other substances) have been administered for a period of at least 4 weeks prior to the diagnostic medial branch block.
Repeat radiofrequency facet denervation may be considered medically necessary when:
-
The above criteria have been previously met to qualify for an initial treatment;
and
- A minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine).
Radiofrequency facet denervation is considered not medically necessary when the above criteria are not met.
The following procedures are considered experimental/investigational:
- Radiofrequency denervation for the treatment of chronic spinal/back pain that does not meet the criteria listed above
- Radiofrequency denervation for the treatment of chronic spinal/back pain when performed at the same anatomic site (side and spinal level) within six (6) months of a prior treatment
- Radiofrequency denervation for the treatment of thoracic or sacroiliac (SI) joint pain
- Pulsed Radiofrequency
- Cryodenervation/Cryoablation
- Laser ablation/laser neurolysis
- Endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy
- Paravertebral facet joint nerve destruction with chemical age (chemodenervation/chemical neurolysis) such as alcohol, phenol, hypertonic solutions, or any other miscellaneous agent
- Therapeutic medial branch blocks Cooled radiofrequency ablation (SInergy).
Procedure Codes
| 27299 | 64490 | 64491 | 64492 | 64493 | 64494 | 64495 |
| 64633 | 64634 | 64635 | 64636 | 64640 | 64999 | A4649 |
