Under sedation and local anesthetic, a needle is directed to the median branch of the dorsal ganglion in the facet joint with fluoroscopic guidance, where multiple thermal lesions are produced by a radio frequency generator.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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
Repeat radiofrequency facet denervation may be considered medically necessary when:
Radiofrequency facet denervation is considered not medically necessary when the above criteria are not met.
The following procedures are considered experimental/investigational:
Radiofrequency Facet Denervation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.